Pressure Injury Malpractice Litigation: A Retrospective Medicolegal Study

ABSTRACT

Medical malpractice imposes a substantial clinical and economic burden worldwide. Pressure injuries (PIs) are amongst the most frequently litigated adverse events and represent a major source of preventable patient harm. To characterise the medicolegal landscape of PI‐related malpractice, the Westlaw legal database was queried for cases litigated between 1990 and 2024. A total of 590 cases met inclusion criteria, with data extracted from court documents. The mean patient age was 71 years; 53.4% were female and 46.6% male. Nursing homes were the most commonly named defendants (59.8%), followed by hospitals and outpatient surgical practices (37.3%) and individual physicians (14.1%). The mean settlement was $383 099, compared with a mean jury award of $2 100 787. Adverse legal outcomes were strongly associated with allegations of inadequate care, poor clinical outcomes and gross provider negligence. When prevention and timely management fail, the consequences extend beyond patient harm to substantial legal and financial liability. Targeted interventions such as standardised risk assessment, rigorous documentation, staff education, appropriate staffing ratios and institutional accountability may mitigate both PI incidence and litigation risk. Strengthening these measures represents a critical opportunity to improve patient safety whilst reducing medicolegal exposure.

Key Points

• Pressure injury malpractice cases most frequently involve elderly, vulnerable patients and commonly arise in nursing home settings, suggesting a disproportionate burden within long‐term care environments.

• Patterns observed in litigation indicate that allegations related to care quality and system‐level factors—such as staffing limitations and management concerns—appear more commonly in plaintiff‐favorable outcomes than wound‐specific characteristics.

• Cases involving severe complications, including infection and death, were more frequently associated with settlements and higher payments, reflecting the potential influence of adverse clinical outcomes on legal resolution.

• Despite the CMS “never event” designation, pressure injury–related litigation has not clearly declined over time, highlighting persistent challenges in prevention and suggesting a need for broader, system‐level approaches to mitigation.

1. Introduction

Medical malpractice accounts for a considerable clinical and economic burden worldwide. Malpractice accounts for an estimated increase of $55.6 billion in spending annually in the United States alone, representing about 2.4% of US' total healthcare costs [1]. Malpractice is defined as an act or omission by a physician that deviates from accepted norms of practice in the medical community and causes an injury to the patient [2]. Malpractice litigation can be employed for a wide variety of adverse outcomes, some of which have merit whilst others fail to meet the standards of direct causation of harm as a breach of duty. Adverse events, which are unintended and frequently preventable injuries attributable to medical management, constitute a major source of medical malpractice litigation [3]. Considerable care is taken in most care settings to prevent medical negligence, including treatment checklists, intensive patient surveillance and precise documentation, processes that are labelled as ‘defensive medicine’. Unfortunately, adverse events still occur, and litigation is a societally acceptable means to hold a negligent party accountable, not just for remuneration but also as a means of deterrence. The statutory requirements for a claim of malpractice in the United States are listed in Table 1.

TABLE 1.

The statutory requirements for a claim of medical malpractice.

Core elements (the four Ds)

Duty – The healthcare provider owed a duty of care to the patient.

Dereliction of duty – The provider violated the standard of care, meaning they deviated from what a reasonably competent professional would do.

Direct cause – The provider's violations was the direct cause of a patient's injury.

Damages – The patient suffered compensable damages, which can include economic and non‐economic losses.

Variable requirements (differs by state)

Statute of limitations – There is a deadline for filing a lawsuit, which is a pre‐set time after the incident occurred.

Expert affidavit – A written affidavit or attestation from a medical professional stating there is a ‘reasonable and meritorious cause’ for the lawsuit.

Required documents – Documents or records related to the incident (e.g., doctor's notes, test results, hospital papers, etc.)

One of the most litigated adverse events is pressure injury (PI). PIs, as defined in 2016 by the National Pressure Injury Advisory Panel (NPIAP), are ‘localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device … as a result of intense and/or prolonged pressure or pressure in combination with shear’ [4]. Approximately 7.5 million new PIs develop globally each year in developed countries and are estimated to affect up to 3 million people per year in the United States at a given time [5, 6]. These numbers have only increased since the COVID‐19 pandemic [5, 7]. According to a 2023 report, PIs are the most frequent preventable hospital adverse event (per the Centers for Medicare & Medicaid Services [CMS]) and the second most common cause of wrongful death claims [8]. Furthermore, according to a study conducted by MagMutual, PIs account for 6% of all litigated medical malpractice suits [9]. PIs alone are estimated to cost $11 billion per year in the United States, £1.4 billion to £2.1 billion in the United Kingdom annually and $1.8 billion in Australia per year [6]. Since the incidence of PIs has been continuously rising since the COVID‐19 pandemic, the total spending caused by PIs has likely also risen [10].

The multifactorial nature of PIs makes them a particularly difficult clinical challenge. PI pathophysiology involves local ischemia and necrosis of an area under pressure. In the presence of prolonged external pressure, a force greater than 32 mmHg is sufficient to impede capillary blood flow [5]. Long‐term external pressure subsequently can cause skin, dermis, subcutaneous fat and muscle to become ischemic and necrotic. Reperfusion also contributes to the development of these wounds by generating increased reactive oxygen species (ROS) which exacerbates the highlighted inflammatory response causing bystander tissue damage and lengthens the overall healing time [5, 11]. Other factors such as friction caused by skin rubbing against clothing or bedding, or moisture from sweat or incontinence, also facilitate the development of ulcers by causing skin breaks in the superficial layers of the skin [5]. The most common areas in which these ulcers occur are the pelvis and hip region as they are the most pressure dependent areas, although PIs can occur anywhere that experience a prolonged force, including the heel and occiput [5].

Whilst PIs can affect anyone who experiences pressure on a specific area of their body, elderly patients are disproportionately affected. Sacral decubitus ulcers are the most common type of PI in this population, with up to two thirds of these ulcers occurring in patients older than 70 years old [12]. A major factor leading to the development of PIs in this population is the intrinsic changes in the skin structure that occur as a result of ageing. Some of these changes include epidermal and dermal thinning, loss of subcutaneous fat and decreased epidermal turnover, which decreases the overall strength of the skin and increases the chance for a bony prominence to exert pressure on the overlying tissue, causing ulceration and injury [4]. Additionally, this population disproportionately suffers from immobility, sarcopenia, incontinence and a loss of the physiologic feedback system that normally induces positional shifts compared to younger individuals, which, coupled with the intrinsic skin changes, considerably increases the likelihood of injury [5]. Common predisposing factors are depicted in Figure 1.

FIGURE 1.

Factors for pressure injury development. Adapted from Woodward, M.C. (1999). Risk Factors for Pressure Ulcers—Can They Withstand the Pressure?

Preventing PIs is widely regarded as an essential responsibility in modern medicine, as these wounds are largely avoidable yet associated with substantial morbidity and significant healthcare burden. To reduce national PI rates, the CMS designated stage III and IV PIs as ‘never events’ in 2008 [13]. A ‘never event’ is defined as a serious, preventable occurrence that should not happen in clinical practice. Other examples include wrong‐site surgery, retained surgical items and certain medication errors. Under this designation, CMS will not reimburse hospitals for additional costs incurred from these injuries or their related complications [13]. However, PIs are not entirely preventable, particularly in patients with intrinsic skin changes, reduced mobility or complex comorbid conditions. Consequently, tying reimbursement directly to clinical outcomes has not demonstrably reduced PI incidence. A 2020 analysis of Medicaid reimbursement penalties even found that PI rates increased after their classification as ‘never events’ [14, 15]. Moreover, the ‘never event’ designation may contribute to increased malpractice litigation involving PIs, given the clearer diagnostic criteria and heightened institutional attention, although trends in PI‐related litigation have yet to be systematically evaluated.

In this study, we conducted a retrospective analysis to better characterise the medicolegal landscape involving PIs. PI litigation was indexed using the Westlaw legal database and relevant case information was extracted. By characterising the medicolegal landscape, we aim to identify common factors contributing to adverse outcomes and inform strategies to better prevent these PIs from occurring in the first place.

2. Methods

The authors performed a retrospective analysis of litigation involving PIs. Cases were indexed from Westlaw legal database (Thomson Reuters Corporation, Eagan, MN) in August 2025. The authors used the following Boolean operators to index jury verdicts and settlements: ‘Pressure Injury’ OR ‘Pressure Wound’ OR ‘Sacral Ulcer’ OR ‘Bed Sore’ OR ‘Decubitus Ulcer’ OR ‘Sacral Wound’ OR ‘Pressure Ulcer’. This search indexed 756 cases. The indexed cases were screened by two independent reviewers for the following inclusion and exclusion criteria:

Inclusion criteria:

1. Legal cases that list a PI (or other synonym) as a reason for litigation.

2. Cases in which litigation is directly related to PI.

Exclusion criteria:

1. Cases prior to 1 January 1990.

2. Cases that do not list a PI (or other synonym) as a reason for litigation.

3. Cases in which the patient incidentally had a PI but it is unrelated to the focus of the legal case.

2.1. Data Extraction

One hundred sixty‐six cases were excluded due to either not meeting inclusion criteria or were duplicate case entries. Five hundred ninety cases ultimately met inclusion criteria and were included for full document review. Case documents were reviewed for patient demographics (age, sex, functional status), treatment characteristics (litigation location, care setting), wound characteristics (new vs. pre‐existing, number, location, stage, complications) and legal case features (defendant, outcome, litigation reason, indemnity payment and expert witness involvement). Data were extracted to a shared Google Sheets document (Google LLC, Mountain View, CA).

2.2. Statistical Analysis

For continuous variables, means with 95% confidence intervals (CIs) were calculated. Associations between categorical variables were assessed using Chi‐square tests, as all analyses met the assumption of adequate expected cell counts given the sample size. Differences between group means were evaluated using the Wilcoxon rank‐sum test due to the non‐normal distribution of the data. Univariable analyses were conducted to evaluate associations between individual predictors and legal outcomes, with results reported as odds ratios (ORs) and 95% CIs. To account for multiple comparisons, false discovery rate (FDR)‐adjusted p values were calculated. Linear regression was used to evaluate relationships between predictor variables and monetary outcomes, with model fit assessed using R ² and overall significance determined by the F‐statistic.

An interrupted time series analysis was performed to evaluate temporal trends in case frequency, modelling differences in rates of cases by year before and after the CMS designation of PIs as a ‘never event’.

3. Results

From the 590 malpractice cases included, the average patient age was 71 years old. Cases were nearly evenly split between men and woman (53.4% vs. 46.6%). Forty‐two percent of cases were resolved by settlement prior to proceeding to trial, and the cases that were tried in court were evenly split between defendant and plaintiff decisions (50.8% and 49.2%). The distribution of states in which litigation occurred is described in Figure 2. An interrupted time series identified a rising PI incidence rate prior CMS distinction as a never event in 2008, and this rate was blunted following never event distinction (Figure 3). Statistical analysis demonstrated that cases resolved by jury trial resulted in significantly higher monetary awards than cases resolved by settlement ($2 100 787.72 vs. $383 099.42; p < 0.0001). Temporal regression analyses did not identify any significant trends in jury awards or settlement amounts across the time period (Figures 4 and 5).

FIGURE 2.

Heat map for distribution of cases by state.

FIGURE 3.

Interrupted time series of PI‐related litigation. An interrupted time series analysis was performed to evaluate the rate of change in annual PI‐related litigation before and after the CMS designation of pressure injuries as a ‘never event’.

FIGURE 4.

Trends in jury award payments over time. The blue points on the graph each represent the amount of a specific jury award for the given year. The graph is overlaid with a line of best fit representing a slight, yet non‐significant, increase in average jury award by year.

FIGURE 5.

Trends in settlement amounts over time. The blue points on the graph each represent the amount of a specific settlement made in a given year. The graph is overlayed with a line of best fit representing a slight, yet non‐significant, decrease in average jury award by year.

Male plaintiffs were more likely to resolve cases through trial rather than settlement compared to female plaintiffs (OR 1.55; 95% CI: 1.10–2.18; p = 0.0091). However, neither plaintiff age nor sex was associated with trial outcomes or payment amounts. Wound distribution is presented in Figure 6. Wound location did not influence case resolution, overall win rates or monetary outcomes (Table 5). There were no statistically significant differences in outcomes based on wound number (trial vs. settlement, p = 0.797; win vs. overall lose, p = 0.778) or wound stage (trial vs. settlement, p = 0.661; win vs. lose overall, p = 0.310). Complications significantly influenced case resolution. Patient death was associated with higher rates of overall plaintiff victories (OR 2.38, 95% CI: 1.57–3.66, FDR‐adjusted p < 0.0001). Cases involving death or infection were more likely to be resolved by settlement, with death showing the strongest association (OR 3.10, 95% CI: 2.16–4.45, FDR‐adjusted p < 0.001), followed by infection (OR 1.65, 95% CI: 1.17–2.35, FDR‐adjusted p = 0.0169). Amputation and osteomyelitis were not significantly associated with settlement frequency. In contrast, complication status did not significantly affect trial outcomes for either the plaintiff or defendant. With respect to monetary outcomes, infection and amputation were associated with significantly higher settlement amounts, whilst no complications were associated with significantly larger jury awards.

FIGURE 6.

Heat map distribution for pressure injury locations. Anatomical pressure injury locations are delineated, with the total number and percentage of overall wounds in each respective anatomic location.

TABLE 5.

Factors associated with legal outcomes and monetary awards in pressure injury‐related malpractice cases.

	OR (95% CI)	p adj
Increase likelihood of trial
Defendant is an individual physician	2.36 (1.39–4.13)	0.0057
Defendant is a hospital or private practice	1.68 (1.18–2.40)	0.0169
Patient sustained wound in a hospital	2.05 (1.44–2.92)	< 0.0001
Patient is a male	1.55 (1.10–2.18)	0.0495
Defendant‐favourable factors
Overall
Defendant is an individual physician	4.29 (2.59–7.17)	< 0.0001
Defendant has expert witness testimony	3.00 (2.00–4.51)	< 0.0001
Plaintiff has expert witness testimony	2.35 (1.60–3.45)	< 0.0001
Patient sustained wound in a hospital	1.65 (1.13–2.41)	0.0429
Plaintiff‐favourable factors
Overall
Defendant is a nursing home	2.43 (1.67–3.56)	< 0.0001
Patient sustained wound in a nursing home	2.34 (1.60–3.42)	< 0.0001
Patient died	2.38 (1.57–3.66)	< 0.0001
Alleged staffing or resource deficiencies	1.87 (1.19–2.99)	0.0314
Alleged wrongful death	2.04 (1.34–3.13)	0.0038
Settlement
Defendant is a nursing home	2.43 (1.67–3.56)	< 0.0001
Patient sustained wound in a nursing home	2.46 (1.72–3.55)	< 0.0001
Suffered infection	1.65 (1.17–2.35)	0.0169
Patient died	3.10 (2.16–4.45)	< 0.0001
Alleged lack of staffing	1.67 (1.14–2.45)	0.0301
Alleged facility or systems issues	1.99 (1.26–3.18)	0.0122
Alleged wrongful death	2.66 (1.85–3.83)	< 0.0001
Monetary differences
Overall
Average jury award > Average settlement	$2 100 787.72 vs. $383 099.42	< 0.0001
Jury awards
Cases alleging staffing or resource deficiencies resulted in higher jury awards	$4 886 988 vs. $1 094 010	0.0336
Settlement
Cases involving amputation resulted in larger settlements	$590 132 vs. $365 539	0.0344
Cases involving infection resulted in larger settlements	$472 196 vs. $316 437	0.0344
Cases alleging staffing or resource deficiencies resulted in larger settlements	$480 711 vs. $342 806	0.0344

Note: The table summarises statistically significant associations stratified by (a) factors associated with increased likelihood of case resolution by jury trial compared to settlement, (b) factors associated with defendant‐favourable outcomes, (c) factors associated with plaintiff‐favourable outcomes and (d) differences in monetary awards. Associations involving binary outcomes are reported as odds ratios (ORs) with 95% confidence intervals and corresponding p values. Comparisons involving continuous monetary outcomes are presented as group means with corresponding p values. Factors associated with plaintiff‐favourable outcomes and monetary differences are further stratified by outcome type. ‘Overall’ reflects combined case outcomes, including settlements and trial verdicts. ‘Trial’ refers to cases resolved by jury trial, and ‘Settlement’ refers exclusively to cases resolved through settlement.

Defendant type was strongly associated with case outcomes. Cases against hospitals, individual physicians or involving wounds sustained in a hospital setting were more likely to proceed to jury trial (OR 1.68, 95% CI: 1.18–2.40, p = 0.0169; OR 2.36, 95% CI: 1.39–4.13, p = 0.0057; OR 2.05, 95% CI: 1.44–2.92, p < 0.0001), whereas cases against nursing homes were more frequently settled (OR 2.43, 95% CI: 1.67–3.56, p < 0.0001). Cases against nursing homes were more likely to overall end in favor of the plaintiff (OR 2.43, 95% CI: 1.67–3.56, p < 0.0001). In jury trials, physicians were more likely to prevail than other defendant types (OR 4.29, 95% CI: 2.59–7.17, p < 0.0001), whilst no single factor was associated with improved plaintiff outcomes at trial. Overall, cases involving wounds sustained in nursing homes were associated with higher rates of plaintiff‐favorable outcomes, whereas wounds sustained in hospital settings or involving individual physician defendants were more likely to result in defendant‐favorable resolutions. Jury awards and settlement amounts did not differ by defendant type. Interestingly, trials involving expert witness testimony were associated with higher odds of defendant‐favorable outcomes, regardless of who the expert witness testified on behalf of.

Thematic analysis revealed that allegations of staffing deficiencies, facility or system‐level failures, and wrongful death were associated with a higher likelihood of settlement. Allegations of inadequate informed consent were more likely to overall resolve in the plaintiff's favour. Defendants were overall more likely to experience losing outcomes when plaintiffs alleged staffing or resource inadequacies, or wrongful death. Cases alleging staffing or resource deficiencies were the only allegation associated with a statistically significant increase in monetary award size, which was associated with both higher jury awards and higher settlement amounts. Statistically significant associations are presented in Tables 2, 3, 4, 5.

TABLE 2.

Summary of patient demographics and distribution of care settings.

	N	Percentage
Patient demographics
Sex
Male	272	46.60
Female	312	53.40
Total	584
Functional status
Limited	138	56.56
Immobile	26	10.66
Hemiplegic/paraplegic	51	20.90
Comatose/unconscious	27	11.07
Other	2	0.82
Total	244
Care setting
Patient setting
Nursing home	362	61.35
Hospital inpatient	241	40.84
Patient's home	8	1.35
Prison/jail	6	1.01
Medical transport vehicle	2	0.33
Both nursing home and hospital inpatient	32	5.42
Other	1	0.02
Total	590

TABLE 3.

Summary of wound characteristics.

	N	Percentage
Wound characteristics
Chronicity of wound
New	548	92.90
Pre‐existing	57	9.70
Both	18	3.00
Number of wounds
1	244	65.24
2	68	18.18
3	34	9.09
4	13	3.48
5+	15	4.01
Total	374
Average	1.63
Stage
I	4	1.80
II	20	9.10
III	15	6.80
IV	175	79.90
Unstageable	5	2.20
Total	219
Location
Sacrum/hips/buttocks	313	78.25
Lower extremity	172	43.00
Back	18	4.50
Head/neck	13	3.25
Upper extremity	8	2.00
Genitals	4	1.00
Chest	2	0.50
Total	400
Complications
Infection	227	38.50
Osteomyelitis	34	5.80
Gangrene	22	3.70
Amputation	50	8.50
Death	221	37.50
2+ complications	168	28.50
Total	590

TABLE 4.

Summary of legal case characteristics.

	N	Percentage
Legal case characteristics
Defendant
Nursing home	353	59.80
Hospital/private physician practice	220	37.30
Physician	83	14.10
Non‐physician practice owner	5	0.85
Nurse	2	0.34
City/state/federal government	11	1.90
2+ defendants	104	17.60
Total	590
Outcomes
Jury trial	325	55.08
Decision for defendant	165	50.80
Decision for plaintiff	160	49.20
Bench trial	2	0.34
Decision for defendant	0	0
Decision for plaintiff	2	100
Arbitration court	5	0.85
Decision for defendant	0	0
Decision for plaintiff	5	100
Settlement	259	42.89
Expert witness involvement
EW for defendant	159	26.95
EW for plaintiff	227	38.47
EW for both	146	24.75
Reasons for litigation
Failure in prevention and risk assessment	430	73.88
Delay in recognition or diagnosis	83	14.07
Inadequate treatment or care	343	58.14
Failure to refer/obtain consults/transfer to hospital	62	10.51
Poor communication and care coordination	73	12.37
Staffing and resource deficiencies	158	26.78
Neglect or abuse	177	30.00
Failure of informed consent	6	1.02
Facility or system‐level issues	98	16.61
Wrongful death	205	34.75
Billing/Medicare fraud	4	0.68
Product misrepresentation/product errors	22	3.73
Documentation failures	43	7.29

4. Discussion

The results of this study highlight the particularly vulnerable population affected by PIs and may suggest strategies to influence both systemic changes necessary to decrease PI development as well as minimise institutional exposure to adverse claim outcomes. As our findings indicate, the average individual involved in malpractice litigation related to PIs is a 70‐year‐old nursing home resident. Nearly half (42%) of cases were settled out of court before trial, perhaps reflecting evidence of substandard care that prompted early concessions by defendants, or felt to not be worth the expense and uncertainty of progressing to trial. Among the remaining cases that proceeded to trial, verdicts were evenly split between defendants and plaintiffs (50.8% vs. 49.2%), which is consistent with the average percentage of cases won by plaintiffs in civil court (56%) [16]. Cases involving nursing home residents were more likely to settle pre‐trial and overall resulted in more plaintiff decisions than cases arising in other care settings. The presence of severe complications, such as infection or death, increased the likelihood of resolution by settlement, likely reflecting both the magnitude of injury and the obvious failures in the plaintiff's care. Likewise, cases alleging staffing shortages, systemic facility failures or wrongful death were more frequently settled, suggesting that these allegations were often well‐supported and difficult for defendants to refute.

Determining culpability in PI cases is complex, as these injuries can be difficult to prevent, particularly in elderly and immobile populations. Elderly patients are especially susceptible to chronic wounds due to intrinsic age‐related skin changes and comorbidities. As Mustoe described, three fundamental factors underlie all chronic wounds: repeated ischemia–reperfusion injury, bacterial colonisation with subsequent inflammation, and cellular and systemic aging [11]. Most patients in this study exhibited all three. The majority (80.3%) were over 60 years old, many were bedbound or wheelchair‐dependent, and most resided in nursing facilities where immobility, poor perfusion and hygiene dependence contribute to repeated ischemic stress and bacterial colonisation. These intrinsic and extrinsic factors, coupled with thinning skin and loss of subcutaneous tissue, make it reasonable to conclude that many of these patients would have developed some degree of PI regardless of the care provided. However, nursing home residents also likely suffer disproportionately from chronic conditions and have longer lengths of stay, amongst other factors compared to individuals sustaining PIs in a hospital setting which may skew the indexed cases to over‐represent nursing home patients.

Nevertheless, the inevitability of some PIs does not excuse substandard care. Preventive diligence remains essential. Although the CMS designation of hospital‐acquired stage III and IV PIs as ‘never events’ represented an important effort to reduce avoidable harm, there is no clear evidence that this policy led to a reduction in overall PI incidence [14]. In fact, a 2020 study suggested that PI rates may have increased following the never‐event designation [15]. Consistent with these observations, our analysis demonstrated a 44% rise in malpractice cases after 2008 (from 13.9 to 20.0 cases per year, p < 0.001, Poisson rate ratio test). Our interrupted time series interestingly identified blunting of the rising PI incidence rate following CMS distinction without clear evidence for PI malpractice rate reduction. Whilst these findings may reflect many confounding factors associated with temporal healthcare or legal changes, it also highlights persistent systemic deficiencies in prevention and management, indicating that alternative strategies may be necessary to meaningfully reduce PI occurrence. Yet, expanded Westlaw coverage, changes in public awareness or reporting requirements, rising nursing home populations, greater institutional scrutiny or differences in malpractice legal standards should not be ruled out as drivers for unimproved malpractice case rates. Taken together, these findings raise questions about whether punitive approaches truly drive quality improvement or whether they inadvertently incentivise the concealment of borderline cases through ambiguous documentation or intentional misclassification.

Our data suggest that the most adverse legal outcomes arise from clear lapses in care, specifically inadequate staffing and staff training. When wounds are ignored or left untreated, they progress to advanced stages, becoming infected and causing avoidable pain, disability or death. Many allegations in our dataset cited suboptimal staffing levels or inadequate staff training, decisions often made to prioritise profit over patient care. Unsurprisingly, these were the cases most likely to settle, as documentation of insufficient staffing or training often provides compelling evidence of negligence. These findings align with prior work from an Australian cohort, which identified deficiencies in nursing education and competency in PI care, as well as inconsistencies in coding and reporting practices, highlighting systemic gaps that limit consistent and effective PI care [17, 18, 19, 20]. Although many of these care gaps are likely unintentional, systemic financial incentives may contribute to persistently low staffing levels in some facilities. Nursing home operators may maintain minimal staffing, recognising that the cost of settlements may be lower than the sustained expense of adequate staffing and comprehensive training. This dynamic may be partially enabled by vague regulatory standards. Under federal regulation (42 CFR §483.35), nursing homes are required to maintain ‘sufficient nursing staff’ to meet resident needs, but this standard is poorly defined, potentially allowing facilities to exploit its ambiguity [21]. Some states have implemented more objective criteria such as minimum staffing ratios or mandated hours of direct care per resident to counteract this loophole [22]. At the federal level, CMS will begin enforcing new minimum staffing requirements in 2026, marking a critical first step towards prioritising patient safety in long‐term care settings [23]. Continued refinement and enforcement of these standards, along with improved staff training and standardised PI identification and reporting practices, will be essential to prevent neglect and improve quality of care.

Despite incremental policy changes, institutional progress in PI prevention remains limited. Current practice relies heavily on risk prediction scales such as the Norton, Braden and Waterlow scales. These tools assess risk using clinical factors like mobility, nutrition and activity, with lower scores indicating higher risk. Although widely adopted, their predictive accuracy for PI development is modest at best. Defloor and Grypdonck found that both the Norton and Braden scales demonstrated low diagnostic accuracy and frequently overpredicted ulcer development [24]. Gurkan et al. similarly reported that whilst the Waterlow scale performed slightly better, all three lacked specificity despite high sensitivity [25]. A recent meta‐analysis by Hillier et al. concluded that there is insufficient evidence that these scales meaningfully reduce PI incidence in clinical practice [26]. The primary limitation of these tools lies in their passive use: they assess risk without directly informing or altering care plans. Many facilities apply uniform repositioning or observation intervals regardless of a patient's score, undermining the scales' potential utility. Instead, documentation of scale completion is often used defensively to demonstrate ‘due diligence’ in the event of litigation rather than proactively guiding prevention. This is not solely the fault of providers; research linking specific risk scores to actionable interventions is limited. Future work should focus on integrating these assessments into adaptive, data‐driven care algorithms. Artificial intelligence and machine learning approaches could synthesise multiple risk variables and generate individualised, evidence‐based prevention protocols, potentially reducing PI incidence across care settings.

Finally, this study fills an important gap in understanding the medicolegal landscape of PIs. To our knowledge, it represents the most comprehensive analysis of its kind. A 2019 abstract in PRS Global Open described a similar investigation using the VerdictSearch database, but that study included only 141 cases and did not publish its full results [27]. In contrast, the present study analysed 590 unique cases using Westlaw, one of the two gold‐standard legal databases, providing a complete and more authoritative dataset. Another study on this topic by Gibelli et al. conducted a systematic review of pressure ulcer malpractice literature [28] This study analysed 12 articles over a 20‐year period and concluded that whilst many PIs are unavoidable, documentation is the most potent method for avoiding liability. However, this study only provides secondary data and does not provide the same granularity as the present dataset.

Nonetheless, several limitations should be acknowledged. First, although Westlaw is a gold‐standard source, it does not capture all cases. Its data are derived from publicly available court documents curated through editorial discretion, meaning that not all trial details are included. Furthermore, our study encounters survivorship bias because cases dismissed before trial, private settlements and arbitrations are not indexed within this database. Thus, the true proportion of settlements is likely underrepresented, and cases are likely biased towards more negligent cases with possibly higher payouts. Second, significant state‐level differences exist in malpractice law, reporting standards and tort reform statutes, which influence case volume and monetary outcomes. For instance, Illinois requires physician certification of merit before a malpractice claim can proceed (735 ILCS 5/2‐622), whereas New York imposes no such requirement, leading to higher case volumes. Differences in statutory caps on damages further contribute to variability in award sizes across jurisdictions. Third, normalised incidence rates – rates relative to persons at risk (nursing home residents per year, hospital admissions, etc.) – were not estimable as they are not consistently reported. Therefore, expanded Westlaw database coverage over time, increased public reporting requirements, rising nursing home populations as baby boomers age or changes in legal standards may account for higher rates in later years.

5. Conclusions

PIs remain a persistent challenge in healthcare, particularly amongst older and medically fragile patients. Despite being classified as ‘never events’, their continued occurrence reflects ongoing gaps in prevention, early recognition and adherence to evidence‐based care. The findings from this study demonstrate that when prevention, care and facility resources are inadequate, the consequences extend beyond patient harm to significant legal and financial repercussions. Strengthening prevention efforts will require the implementation of coordinated, multifaceted programmes that integrate consistent risk assessment, staff education, adequate staffing, standardised surveillance and institutional accountability, rather than reliance on isolated interventions. These comprehensive models have the potential to improve PI identification and management whilst reducing both incidence and litigation risk. Ultimately, sustained institutional commitment to proactive, high‐quality care is essential to protect vulnerable patients and uphold the standard of care.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.