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Written on 15th June 2022 by Susan Brown

NHS Resolution has published the results of its review of clinical negligence claims relating to diabetes and lower limb (foot and leg) complications.

The NHS’s defence organisation and claims handler analysed 92 medical negligence claims arising mainly from lower limb amputations suffered by people with diabetes. The reviewed claims related to injuries which occurred after 2012/13 and included cases in which liability (fault) had been admitted or denied by NHS Resolution, but were settled after 2018/19.

Of the 92 patients with diabetes whose claims were reviewed, 55 had undergone a major lower limb amputation. These major amputations included below (62%) or above (22%) knee amputation, or amputation to both legs (9%). In addition, 30 had undergone minor amputations. Their claims were analysed to identify recurring themes in their NHS care, and highlighted multiple failings at every stage of the care that people with diabetic foot care problems receive.

Diabetes and lower limb amputations

Diabetes is a worldwide health epidemic which continues to increase as a result of rising obesity, lifestyle changes, and an aging population. It is predicted that over 640 million people will have the disease by 2040.

Diabetes is a lifelong condition in which a person’s blood sugar level becomes too high. Complications of the disease include blindness from retinopathy, kidney disease, damage to nerve function and sensation (neuropathy), cardiovascular disease and peripheral artery disease (PAD).  These life-threatening complications of diabetes have a serious effect on the person’s health and increase the risk of  heart attack, stroke and limb amputations.

Nearly 8000 major diabetic lower limb amputations were carried out in England between 2017 and 2020. However, it is thought that 85% of diabetic amputations are avoidable.

Most lower limb amputations occur in people who have had diabetic foot ulcers. Diabetic foot problems must be taken seriously and treated promptly to avoid amputation. High blood sugar can cause nerve damage (neuropathy) which reduces the blood circulation to the patient’s feet, prevents wounds from healing and increases susceptibility to infection. To make matters worse, patients with diabetes are less likely to see or feel any minor wounds on their feet as a result of their neuropathy or visual impairment. This means that preventative care, early diagnosis and prompt specialist treatment of foot conditions when they arise are essential to avoid amputation for these vulnerable patients.

Findings from NHS Resolution’s review of claims by people with diabetes and lower limb complications

NHS Resolution’s review found failings in the care that patients with diabetes received for lower limb problems at every stage of their treatment.

Patients who were at high risk of lower limb complications leading to amputation were not identified and received very minimal preventative care. For example, the review identified that although 85% of patients were in the high risk category, only 5% were identified as high risk during their care. 68% of the reviewed patients with diabetes had never been seen by a foot protection service (FPS) or community podiatry team before the onset of their foot complications.  Where assessments took place, they were brief and incomplete.

Once diabetic foot problems were identified, usually initially by a GP or in A&E, 68% of patients experienced delays in being referred to a specialist footcare team. 29% of patients experienced delays in being seen by the specialist footcare team after their referral had been sent, with 20% needing multiple referrals to the FPS or multidisciplinary footcare team (MDFT) before finally being seen.

When specialist footcare was provided, it was irregular and relied on the patient’s GP to ensure that the patient continued to receive the specialist care. 52% of patients received no MDFT input at any stage, and 64% of patients didn’t receive consistent ongoing reviews by a specialist footcare team, even after they had been referred and reviewed. In 98% of the patients who underwent a major amputation, the decision to proceed to amputation was not made through an MDFT. Only 3% of patients received input from an MDFT team that included podiatric, medical, surgical and either microbiology or infectious disease specialists.

Diabetic foot disease was poorly managed, with a lack of evidence-based assessments and interventions for foot ulcers, leading to delays in recognising the extent and severity of the patient’s disease, or it not being picked up at all.  88 of the 92 patients whose care was reviewed experienced a diabetic foot ulcer at some point during the events which resulted in their injury and subsequent claims. NHS Resolution identified failings in various aspects of the treatment of their foot ulcers, including delayed, incomplete or lack of debridement (cleaning out the dead tissue from a wound), delays or errors in microbiology testing for infection, failure to carry out or errors in performing and interpreting the results of x-rays and scans in conjunction with the other aspects of the patient’s clinical condition.

The significance of weightbearing and the importance of relieving pressure on the foot was not recognised. 58% of patients received no ‘offloading’ intervention at all.  Where ‘offloading’ took place it was ineffective, or provided too late in the progression of the patient’s disease or deformity. Only 4% of patients were seen by a physiotherapist to help them safely take pressure off their diabetic foot ulcer.

There was no clear process for hospital admission or discharge. 37% of patients were not admitted on presentation to A&E on at least one occasion. NHS Resolution found 25 different scenarios by which the reviewed patients were admitted to hospital. Some were admitted from A&E, whereas others were admitted with help from the vascular surgeons or their GP. Only 2% were admitted after being escalated from the community footcare service directly to the MDFT.  72% of patents had multiple admissions to hospital for the same medical problem. 95% of those patients who had multiple admissions to hospital were discharged before their wounds had healed, and following poor planning and outpatient follow up they quickly suffered further deterioration.

Some of the reviewed patients experienced delays in assessing and managing peripheral artery disease (PAD), a known cause of serious illness including limb loss and amputation.  Vascular assessments were delayed, with patients waiting an average of 90 days between the discovery of their tissue loss and vascular investigations, and a further 50 days before revascularisation (to restore the blood flow to the affected limb). Vascular assessments were brief and inaccurate, with frequent failure to use handheld Dopplers to assess the patient’s pulse, and failure to consider relevant aspects of the patient’s medical history or ongoing symptoms. 97% of patients who underwent revascularisation did not have MDFT follow up after the procedure.

The review also found a lack of education and self-care advice, and support for the emotional and social difficulties which often affect people with lower limb complications from diabetes, which contributed to high levels of patient non-compliance.

Overall, NHS Resolution’s review of claims relating to lower limb complications including amputation in people with diabetes found common, worrying themes throughout the NHS care that these patients had received. These included:

  • Failure to recognise the severity of the patient’s condition;
  • Lack of urgency in delivering care and failure to comply with recommended referral and review times in guidelines;
  • Lack of thorough, evidence based assessments, such as the depth of foot ulcers etc ;
  • Poor documentation and inconsistent terminology, meaning that vital information is not correctly passed on to other clinicians who are treating the patient;
  • Lack of properly integrated multidisciplinary care even when multiple different specialists are involved, and lack of clear pathways or overall coordination and responsibility for the patient’s care;
  • Lack of escalation or changes to the patient’s management plan when the patient’s condition changes;
  • Failure to consider that the patient’s lack of pain may be the result of diabetic neuropathy, rather than an indication of health, requiring more thorough investigation to understand the true severity of the patient’s condition.

These failings resulted in unacceptable delays in the diagnosis, specialist referral and treatment of foot conditions in patients with diabetes, and amputations which could and should have been prevented.

NHS Resolution’s recommendations include the introduction of properly implemented and audited standards to improve the care of diabetic patients with lower limb complications.

Compensation for amputation caused by negligent diabetic foot care

Boyes Turner’s medical negligence specialists have recovered compensation for many clients with diabetes who have suffered amputations as a result of negligent care. Through compensation we help our amputee clients restore their mobility and independence enabling them to lead active and fulfilling lives, despite their amputation. 

If you are disabled from amputation or other serious injury as a result of medical negligence and want to find out more about making a claim, you can talk to one of our solicitors, free and confidentially, by contacting us here.