Diabetes and Avoidable Amputations: What Do the Reported Legal Cases Tell Us?
When do mistakes in managing diabetic patients lead to avoidable amputations? What can we learn from the reported cases and how can good care avoid further medical negligence claims?
Most successful claims are resolved by negotiation rather than trial. Few are reported. So the evidence base is limited. However the reported cases can give us an insight into what goes wrong and what results in claims.
Diabetic Foot Injuries: GP Failures to Refer
By far the most common problem is GPs failing to refer foot injuries early enough. This is the most common type of reported case. They are also the cases most often encountered in practice.
NICE Guideline [NG19] (Diabetic foot problems: prevention and management) requires GPs to immediately refer patients with limb-threatening or life threatening diabetic foot problems. These problems include ulceration with fever or any signs of sepsis, ulceration with limb ischaemia, clinical concerns of deep–seated soft tissue or bone infection and gangrene. For all other active diabetic foot problems patients should be referred within 1 working day to the multidisciplinary foot care service or foot protection service. Earlier versions of the Guideline were similar.
It is this latter category that seems to cause problems. Diabetic patients with cuts, infections, blisters or ulceration to the feet are often treated by the GP, practice nurse or district nurse and not referred at the earliest opportunity. This often means that management is ineffective. Typically the wound will be dressed but the foot not off-loaded. There will be no review of diabetic control by endocrinologists and no assessment of circulation by the vascular team.
In case of SJ v Cullen and others, an 82 year old diabetic man tripped and injured his big toe. He consulted doctors and nurses at his surgery on numerous occasions between over a 5 month period but was not referred. His wound was treated with creams and painkillers. It was dressed by a district nurse twice per week. It gradually worsened and by after 4 months the middle toe was black and he had cellulitis. The foot became gangrenous. By the time he was admitted to hospital it was too late to avoid an amputation. Initially he lost half the foot and then 6 months later his leg was amputated below the knee. He had a prosthesis fitted but struggled to adapt.
2 other cases illustrate the same failure.
In S D v N a diabetic man (the report does not give his age) consulted his GP between over a 4 month period with an ulcerated toe on his left foot. The GP treated him with antibiotics but did not refer him. He deteriorated. Eventually he went to A & E where a doctor recommended admission. The man consulted his GP who advised that admission was unnecessary. He continued to deteriorate. By the time he was eventually admitted as an emergency it was too late to avoid a below-knee amputation.
In B v P and others a 62 year old man with type 2 diabetes consulted his GP with an injury to his right foot. He was seen on several occasions by the GP, practice nurse and podiatrist over a 2 week period by not referred. Again, by the time he was referred to hospital it was too late to avoid a below-knee amputation.
Charcot arthropathy is an uncommon condition but it is one that gives rise to claims from time to time. Patients have neuropathy or altered sensation in the foot. They suffer fractures often as a result of minimal trauma. They are often unaware of the injury and continue to walk on a degenerating foot, making the damage worse. Typically the midfoot will collapse and a ‘rocker bottom’ deformity develops. Swelling, inflammation, warmth in the foot and increasing deformity and all indications of the condition. Delays in recognising Charcot arthropathy worsens the outcome and can lead to claims.
An example is LL v Dr O’Reilly and others. The case is in fact not just an example of delayed diagnosis of Charcot arthropathy but also a failure to comply with NICE guidelines by referring a new diabetic foot ulcer to a multi-disciplinary foot clinic. A 57 year man with type 2 diabetes developed a blister on his left midfoot. He was seen repeatedly at his GP’s surgery. He was not referred to hospital for 4 months by which time he had intractable ulceration, infection in the wound and osteomyelitis. He had also developed Charcot arthropathy with collapse of the midfoot and had a rocker-bottom deformity of his foot. He was at risk of amputation.
In practice not all delays are due to poor GP care. This is a condition which is sometimes missed in Emergency Departments, by endocrinologists during diabetic reviews and even by orthopaedic teams.
Failure to Avoid Pressure Sores
It is not only patients with diabetes who are at risk of pressure sores. However, the patients may have poor circulation, a factor which increases the risk. Most pressure sores are avoidable with adequate risk assessment and steps to reduce the risk. Those steps include regular changes of position, pressure relieving devices and good nutrition.
RC v University Hospitals Bristol NHS Foundation Trust and North Bristol NHS Trust is a case where a 62 year old woman was admitted to hospital with a broken hip. She had diabetes, vascular disease and smoked. The case report gives little information as to what pressure assessment was carried out and what steps were taken to reduce the risk of damage. However, she developed avoidable pressure sores on both heels. Vein transplants failed to restore good circulation. 2 months after her admission she underwent a below-knee amputation of the left leg. Her recovery was poor and she developed infections of the stump which proved difficult to manage. A year later she needed an above knee amputation.
Delayed Diagnosis of Vascular Problems
Diabetes increases the risk of vascular disease. Poor control of blood sugar levels causes narrowing of blood vessels (atherosclerosis). There are several reported cases where negligent delays in diagnosing vascular disease have led to successful claims. Some patients have developed critical limb ischaemia. In one case a patient had toes amputated. Another lost fingers. A third had a below-knee amputation. Again the small number of reported cases distorts the picture because in practice the most common amputations are often of the leg below the knee.
VP v HWPH is an interesting case because critical limb ischaemia developed in the arm rather than the leg. A 58 year old woman with poorly controlled diabetes also had high blood pressure, was obese and smoked. All these factors increased her risk of vascular disease. She developed pain and colour-change in both hands (both possible indications of critical limb ischaemia). However when she saw doctors the overall picture was confused by a background of generalised weakness, fatigue and muscle pain.
She went to her local Emergency Department. The examining doctor noted discolouration of her fingers and cyanosis of her index and middle fingertips. He thought she had Reynaud’s Disease and sent her home with advice that her GP should refer her. The next day she had shooting pains through 3 fingers of the left hand and one on the right. On the third day her fingers had turned grey, her hands were swollen and her pain had increased. She was taken back to the Emergency Department by ambulance. Because her GP had already made a referral she was told there was nothing more to be done.
On the fifth day she deteriorated further and her GP referred her to hospital. She was found to have digital ischaemia and gangrene. She underwent amputation of 2 fingertips.
A final type of common case is the mismanagement of infection. Patients with diabetes may have suffered damage to the immune system, nerve damage and reduced circulation. This can increase the risk of infection. In some cases poor management of infection elsewhere causes significant harm and can give rise to amputation.
An example is Perkins v Hywel Dda Local Health Board. A 70 year old man with type 2 diabetes had a left total knee replacement. He developed a post-operative infection and was treated with Flucloxacillin. A swab was reported as showing Group B Streptococcus and the microbiologist recommended Amoxicillin. As a result of a negligent mistake, his antibiotics were not changed. He deteriorated. A month later he needed debridement of the wound. After a further 3 months he needed a 2 stage revision procedure to replace the prosthesis. He subsequently needed 2 more procedures to debride and wash out the wound. Ultimately he had an above-knee amputation.
These reported cases are only a very small sample of resolved claims. They are not therefore entirely representative. However they do given an indication of the most common type of case where mistakes in managing patients with diabetes give rise to amputations.
In practice the most common category of diabetic amputation case is where GPs fail to comply with NICE guidelines by making urgent referrals to multi-disciplinary diabetic foot clinics. From a legal perspective that is surprising. The guidelines are clear. They may assume that clinics are more readily available than is in fact the case. For instance although they require urgent referral, the patient may not be seen for a week where specialist clinics only take place once per week. So even an urgent referral may lead to an enforced delay of 7 days. But many of cases involve longer delays without which the patient would have avoided amputation.
The other categories of case are also reasonably common. These included the delayed diagnosis of Charcot arthropathy, failures to prevent pressure sores, delays in diagnosis vascular problems and the mismanagement of infection. Some of these problems are not unique to diabetic patients: the elder may also be particularly vulnerable to pressure sores. However, complications of diabetes increases the risk.
It is important to know what mistakes lead to successful claims if clinicians are to work out how to improve care. If you feel that you have received poor medical care and would like to discuss it, please call us today on 0800 044 8488 for a free, confidential conversation.