Text size

Theme

Language

"Iatrogenic pressure sore"

About: Geraldton Hospital

(as a parent/guardian),


My parent-in-law, a non-ambulatory (bed-bound) elderly patient, was admitted to the Geraldton regional hospital for inpatient management of a urinary tract infection (UTI) and COVID-19 pneumonia in which I felt they received excellent treatment, however during their five-day hospitalization, they developed an unstageable pressure injury (decubitus ulcer or bedsore) on their heel, consistent with a hospital-acquired pressure injury (HAPI) secondary to prolonged immobility, inadequate repositioning, and potential deficits in skin integrity monitoring protocols.

This injury was neither identified, documented in the medical record, nor communicated during discharge handoff. Upon transfer back to their long-term residential care facility, the receiving nurse noted the presence of the pressure injury during initial assessment however the transferring staff from the regional hospital explicitly stated that the patient had no existing pressure injuries at the time of discharge.

However, I believe the clinical severity and progression of the unstageable lesion-obscured by a Bulla or eschar—strongly indicate that it was iatrogenically acquired during the hospital stay and as I understand such injuries typically evolve over several days under conditions of sustained pressure and shear forces in vulnerable, immobile patients.

It is obvious to me that this injury should have been picked up prior to discharge however, in my opinion it is clear to me that procedures are not being followed. I apologize to all the hardworking staff and know you strive to provide outstanding care for your patients and community... But I feel that maintaining silence fails to ensure improvement.

Staff skills

Staff skills

Treatment

Treatment


Do you have a similar story to tell? Tell your story & make a difference ››

Responses

Response from Cameron Ross, Operations Manager Geraldton Health Campus, Midwest, WA Country Health Service 4 days ago
Cameron Ross
Operations Manager Geraldton Health Campus, Midwest,
WA Country Health Service

Operations Manager Geraldton Health Campus

Submitted on 12/08/2025 at 1:14 PM
Published on Care Opinion Australia at 4:48 PM


picture of Cameron Ross

Dear healthincrisis40+,

Thank you for taking the time to contact us via Care Opinion.

I sincerely appreciate your advocacy on behalf of your parent-in-law and acknowledge the concerns you have raised regarding the development of a pressure injury during their inpatient stay at Geraldton Health Campus (GHC). Please be assured that GHC take such matters very seriously.

The prevention and management of pressure injuries in patients with limited mobility is a complex and ongoing challenge. Our clinical teams are committed to delivering comprehensive care and implementing best-practice strategies to minimise the risk of such injuries. Nonetheless, we recognise the importance of reviewing individual cases to ensure continuous improvement and accountability.

I would welcome the opportunity to speak with you personally to further understand your concerns and provide any additional support or clarification you may require. My name is Cameron Ross, and I am the Operations Manager at Geraldton Health Campus. You are most welcome to contact me directly on (08) 9956 2369 at your convenience.

Thank you again for bringing this matter to our attention. We value your feedback and remain committed to delivering safe, respectful, and high-quality care to all our patients.

Regards

Cameron Ross

Operations Manager Geraldton Health Campus

Tel: 9956 2369

  • {{helpful}} {{helpful == 1 ? "person thinks" : "people think"}} this response is helpful
Opinions
Next Response j
Previous Response k