Case studies

As well as John, Rangi, Danny and Kate’s stories below, the Commission has worked with both patients and providers to produce the following case studies aimed at building the case for change and providing readers with tips about how to approach pressure injury prevention projects.

The case studies detail the patients’ personal stories and the impact the pressure injury had on them and their family and whānau, and also tell the story of how the health care providers changed their processes and practices as a result, to prevent similar incidents happening again.

Patient stories (names have been changed to protect privacy)

John's story

John, a widower of 71 and recently retired, was admitted to hospital with an ischaemic leg. Prior to admission his mobility had decreased quickly over the last two days and he was unable to walk. He has a medical history of heart disease, peripheral vascular disease, diabetes and COPD, making him extremely susceptible for developing a pressure injury if timely prevention is not put in place. His words create the following story.

‘When I transferred to the hospital, I had to wait 36 hours in the emergency department before a bed was available. During that time, I was unable to move and became incontinent.

‘I told the doctors and nurses that I had a sore bottom but no one paid attention to it.’

John was admitted to the ward without a pressure injury risk assessment, and this was not completed until day four. The nursing notes stated that John had a reddened area on his sacrum. However, there is no record of a preventive intervention being put in place. On day ten, two days after his operation for a below-knee amputation, the sacral pressure injury was re-observed and documented as Grade III. Only at this stage was a pressure-relieving mattress ordered and a wound care specialist consulted.

The prolonged rehabilitation time caused him considerable pain and isolation. Reflecting on the ordeal, he said:

‘The wound itself was mostly numb due to it being so deep. I remember the smell from the wound, which was terrible. I found it embarrassing and did not want any visitors. The most disappointing part was not being able to get on with my rehabilitation following the amputation. It felt like my life was put on hold. At times I was frustrated and annoyed but put on a brave face for the staff.’

John’s case highlights how simple preventable action in the ED could have saved considerable suffering, and the importance of frequent assessment when immobile.

Rangi’s story

Rangi is a 41-year-old Māori man who has been tetraplegic for 20 years. He is very aware of the dangers of pressure injuries and is proactive in every way to prevent them from occurring. Nevertheless, they sometimes develop and require treatment. When they do, this is what he experiences:

Increased social isolation

‘I miss out on whānau meetings as I have to lay prone for long periods of time. This isolates me from what is going on in my family.’

Loss of upper body strength

‘Lying prone in bed reduces the strength in my upper arms as I am not using them as much as I would do when I am in my wheelchair. So every time I have to make sure I get back in to shape.’


‘I missed out on a couple of important school meetings of my children.

‘I missed those important moments where, with all the other parents, you are proud of what they have achieved.’

Pressure injuries also affect Rangi’s wife and the rest of the family.

Not having her husband at the school ceremony made her feel as though she was being seen as a single parent.

Lack of understanding

‘The public is not aware of how dangerous and debilitating pressure injuries are. Information is crucial so that when I ask for a comfy seat, people do not question that request.

‘Also, the DHB needs to understand that my own equipment is crucial to me. During one of my visits they took it away and my own family had to make sure that I was turned regularly.’

Danny’s story

In 1999, Danny was a forestry worker, when a rotten tree behind where he was working fell on him. Danny’s story, told in an interview as part of this project, is as follows:

‘I knew straight away I had a spinal injury and I would probably never walk again, but didn’t know what this meant for my future.

‘After months of treatment and rehabilitation, I vowed that I would not let this get me down. I took up wheelchair basketball soon after my rehabilitation finished. In 2002 I was selected to represent New Zealand in wheelchair basketball at the Far East and South Pacific Games for the Disabled, held in Korea.

‘I continued to play basketball for New Zealand with a dream of going to the Paralympics, in 2009. I took part in the “Accelerate to Excellence” programme run by Paralympics New Zealand and was introduced to rowing, training every day for six months and finally trialling for the world championships in 2010 at Karapiro.

‘I made the cut for the team! I had a great regatta and against all expectations won a bronze medal at the champs. I then went on to the world champs in Slovenia in 2011 and qualified the boat for the Paralympics in London in 2012, where I came first in the 1000 metre B-final.

‘I am very much a family man. My partner and I have five kids. I live on a 2.5-acre lifestyle block, on which I run a couple of cattle. I have my own health and safety business and it is rare to find me “sitting still”.

‘My battle with pressure injuries started when I had to sit on a plane for a long time without a pressure reducing cushion. This caused my skin to break down and it took a considerable time to heal, this was on the plane to the world champs in Slovenia in 2011.

‘The second occasion occurred after the Paralympics in 2012. I made sure I had prevention material in place; but again the journey in combination with the physical stress of the rowing caused the skin on my buttocks to break down. This time it did not heal by itself and I needed surgery.

‘Last September the skin broke down again due to unknown cause. The wound did not heal, and ultimately became infected, and I ended up in hospital. Currently I am on the waiting list to receive surgery.

‘Having a pressure injury seriously affected my life. As the pressure injury is on my buttocks, I cannot sit properly in my wheelchair and have to lay most of the time on a bed or in my Lazyboy. I only can work for a couple of hours each day, and having my own business I had to hire additional staff to make sure the business survived.

‘Prior to the pressure injury I did site visits for work but now that is not possible. I now spend most of the time immobile, which affects my physical strength especially my arms. This is important as I now find it difficult to move from my wheelchair into the car. It is also difficult to lift my buttocks from the wheelchair or chair so that the skin and muscle get sufficient oxygen and build-up of fluids caused by pressure are removed.

‘You can imagine that having a pressure ulcer also affects my family life. It has been more than four months since we were able to go out and socialise together. I now cannot attend important occasions for my partner and children. Going out for a coffee has become a real treat.

‘It’s also the social aspect of being laid up that I find hard. Although I have a regular flow of visitors and friends; and the family has been awesome, it is the fact that I am stuck at home 95 percent of the time that gets me.

‘Even in a wheelchair I am a keen pig hunter and I feel sorry for my dogs who are not getting the work and exercise that they are used to getting. Now they have started playing up around the home, digging holes, escaping from their paddock and tricks like that.

‘Perhaps the biggest problem I find is explaining to others why I cannot do what I used to do. Pressure ulcers are literally a hidden ugly issue. The wounds are on locations you do not want to show off, they are nasty, and they smell, especially when they are infected. Once you have them, it is very hard to get rid of. It is also very hard to explain to others as they either have no idea what you are talking about, or have no idea how seriously they affect my health. In my opinion, the topic of preventing pressure injuries needs to be addressed more prominently in New Zealand.’

Kate's story

Kate shares her story of getting an unexpected pressure injury following the birth of her baby.

On the day of her elective caesarean, Kate was focused on getting through the surgery safely with a healthy baby.

‘I arrived at 7 am and was prepped for surgery as my baby was breech, but I was left waiting for several hours due to other emergency presentations. By this time, I had started to go into labour and when the umbilical cord prolapsed I was whisked into theatre for an emergency caesarean.’

She delivered a beautiful healthy baby girl in 45 seconds but had to face other complications; a torn bladder meaning a catheter was put in place. The postnatal wards were full, so she was kept in the delivery suite overnight.

‘When I finally made it home, I noticed the skin over my tailbone was extremely tender and hot to touch. It took a couple of days but the skin turned hard, like the top of a large blister and eventually peeled off.’

‘I later discovered that this was a pressure injury and that it was totally preventable. In sharing my story I’m not attaching blame to the care I received. I was fortunate: this was a relatively minor injury and it healed quickly.

Kate now knows the injury occurred because she was immobile for many hours whilst recovering from the surgery, in a bed that wasn’t appropriate. The bed in the delivery suite was a plastic mattress covered by a thin sheet. It may have been appropriate for short term delivery but it was very uncomfortable for a long duration and this was not checked by staff at the time. Kate should have been given a more appropriate bed and also assisted to change her position at regular intervals so that pressure didn’t build in one place.

Kate says that the lesson she’d like to pass on is that ‘any time spent under similar circumstances puts anyone at risk, even a healthy, mobile person like I was, and needs to be monitored, and action taken to prevent and manage the injury.’

Pressure injuries are preventable and raising awareness of risk factors and simple steps to take to prevent them will minimise harm and discomfort for patients.

Gabrielle Nicholson, project manager for the Health Quality & Safety Commission’s pressure injury prevention programme says there are globally recognised ways to reduce the risk and impact of pressure injuries.

‘The SSKIN bundle, for example, provides a useful way to make sure all of the correct steps are taken to prevent pressure injuries from occurring.’

The SSKIN bundle includes the following steps:

  • Surface – provide a supportive and pressure-relieving surface
  • Skin inspection – undertake regular checks for discolouration and pain on bony areas (such as hips and heels) and under or around medical devices
  • Keep moving – change position often
  • Incontinence – keep skin dry and clean
  • Nutrition – eat healthily and drink plenty of fluids.

A great starting point for all health professionals, carers and people giving and receiving care is the Guiding principles for pressure injury prevention and management in New Zealand published in 2017 and available on the ACC website.

Last updated 22/02/2021