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This is a retrospective case study about severe pressure ulcers and why healthcare services may contribute to people developing them. Pressure ulcers are caused when skin and tissues are damaged as a result of pressure. They range in severity from non-blanchable erythema (Category 1), superficial skin loss (Category 2) to large wounds involving fat, muscle and bone (Category 3/4). Category 3 and 4 pressure ulcers are also referred to as severe pressure ulcers (EPUAP/NPUAP, 2009, NHS Improvement, 2018). These can contribute to death. Although there is little known about how patients develop severe pressure ulcers, this study offers possible explanations. As well as the main finding that the health care environment contributes to the development of severe pressure ulcers; four possible explanations are i) patients not being heard, ii) decision making in complex environments, iii) safety culture lacking in mindful awareness and iv) diffusion of responsibility and poor communication between staff, wards and health care services. These also link into a model of intervention. The study's method offers a way of investigating pressure ulcers retrospectively, which differs from current techniques. The main difference is the focus on the patient's or carer's view as the primary source of evidence, in contrast to the current focus on service level investigations. This study offers a 'Safety III' approach which combines empirical (correspondence) approaches of investigation with coherent (rational, explanatory) approaches. The study recommends including patients and carers in investigating severe pressure ulcers, empowering nurses to make decisions regarding pressure ulcer care and working towards a 'mindful' safety culture.