Pressure Ulcers and Malnutrition: The Nutritional Limb of a Pressure Sore Claim

Pressure ulcer claims are usually framed as nursing cases. The allegations concern risk assessment, repositioning, pressure-relieving equipment and wound care, and the experts instructed are typically in tissue viability and nursing. Nutrition is often present in the records and absent from the analysis.

That is a gap worth closing. Malnutrition is both a risk factor for pressure ulcers and a determinant of whether they heal, and the nutritional care of an at-risk patient is subject to its own standard. As an HCPC-registered dietitian, I am instructed in matters where the nutritional limb of a pressure ulcer claim is material.

The standard of nutritional care

NICE guideline CG179 on the prevention and management of pressure ulcers treats nutrition as part of both prevention and treatment. It recommends that nutritional supplements should not be offered specifically to prevent a pressure ulcer, or to treat one, in adults whose nutritional intake is adequate, and that adults with a pressure ulcer who have a nutritional deficiency should be offered them. The logic is that nutrition is targeted at an identified need, which only works if the need has been identified. For children and young people with a pressure ulcer, CG179 recommends an age-related nutritional assessment by a paediatric dietitian or other healthcare professional with the necessary skills and competencies, and discussion with a paediatric dietitian about whether to offer supplements.

The international clinical practice guideline published in 2019 by the European Pressure Ulcer Advisory Panel, the US National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Alliance sets out quantitative targets for adults with a pressure injury who are malnourished or at risk of malnutrition: 30 to 35 kcal per kilogram of body weight per day, and 1.25 to 1.5 g of protein per kilogram per day, adjusted to the individual. Hydration is assessed alongside. In England, Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires registered providers, hospitals and care homes alike, to meet the nutritional and hydration needs of the people in their care.

Taken together these define a sequence: screen for malnutrition, identify the at-risk patient, refer where indicated, estimate requirements, deliver nutrition that meets them, and monitor whether it is being taken and whether it is working.

What inadequate care looks like

The recurring failures are at the joins in that sequence. A pressure ulcer risk assessment records poor nutrition and nothing follows it. A malnutrition screen is completed on admission and not repeated as the wound deteriorates. A supplement is prescribed and the charts show it was rarely taken. A falling weight is recorded without anyone connecting it to the wound.

In one recurring class of case, an older patient is admitted after a fall, develops a sacral ulcer within days, and is seen by tissue viability and given appropriate equipment. No referral to a dietitian is made. Over several weeks intake charts show meals largely refused, the weight falls, and the ulcer progresses. Every pressure-relief step is documented. The nutritional limb of the plan was never written.

The evidential question

The records that carry the analytical weight are the malnutrition screening documentation, the pressure ulcer risk assessments, every recorded weight, food and fluid charts, the drug chart for supplements prescribed and administered, any referral to a dietitian and its outcome, and wound assessments over time. Reading them side by side matters: the nutritional failure often only becomes visible when the wound chart and the weight chart are on the same page. An absent record is itself a finding.

Standard, breach and causation

Breach is judged against what was reasonable at the time, not with hindsight. Causation is often where these claims are decided. Pressure ulcers are multifactorial: pressure and shear are the primary mechanism, and immobility, perfusion, continence, comorbidity and nutrition all contribute. In a civil claim causation is decided on the balance of probabilities, and the dietetic expert's task is to address what the nutritional failure contributed, distinguishing it from what the patient's condition and other aspects of care would have produced regardless. An opinion that overstates nutrition's part will not survive scrutiny, and neither will one that ignores it.

What a dietitian should not address

Whether repositioning frequency was adequate, whether equipment was appropriate, how a wound was graded or dressed, and whether a deep ulcer caused or contributed to sepsis or death are for tissue viability, nursing and medical experts. The dietitian's lane is nutritional risk, requirements, referral, delivery and monitoring.

A note on forum

Pressure ulcers also arise in safeguarding enquiries and in CQC enforcement, and CQC enforcement can include prosecution: it is a criminal offence for a registered provider or manager to fail to meet Regulation 12 (safe care and treatment) or Regulation 14 of the 2014 Regulations where the failure results in avoidable harm to a service user, or exposes them to a significant risk of it. At the extreme there are also prosecutions of individuals or care providers for ill-treatment or wilful neglect. In any prosecution the standard of proof is the criminal one. What is said here about the balance of probabilities applies to civil claims only. An expert instructed in any other forum should have the governing standard confirmed in the letter of instruction.

Practical guidance for instructing solicitors

Records to obtain include: malnutrition screening and pressure ulcer risk assessments for the whole admission or placement; all weights; food and fluid charts; the drug chart; dietetic referrals and notes; wound assessments and photographs; and the care plan, including any care home malnutrition plan.

Key instruction questions: Was nutritional risk identified, and when? Was referral to a dietitian indicated, and made? Were requirements estimated and met? Was intake monitored, and was a falling intake or weight acted on? On the balance of probabilities, what did any nutritional failure contribute to the development or progression of the ulcer?

Independent dietitian expert witness

I provide independent expert evidence on the nutritional aspects of pressure ulcer claims, for claimant and defendant instructions, alongside tissue viability and nursing experts rather than in place of them. If nutrition sits anywhere in the records of a pressure ulcer matter, it is worth a conversation before the experts are fixed.

Rick Miller BSc., MSc., RD

Consultant Registered Dietitian

HCPC DT25651