Pressure sores cause significant mortality and morbidity as well as being a financial burden on health-care services. Reduction of pressure sore incidence is a Department of Health priority. Pressure sores are accepted as largely preventable complications of illness and disability and the means to achieve prevention are available. The aim of this clinical audit was to identify potential contributing factors to pressure sore acquisition in an acute hospital setting. The results suggest that substantial changes in the approach to clinical management may be needed.