At Hill Dickinson we have dealt with numerous clinical negligence claims concerning the management of diabetic patients, at both a primary and secondary care level. We know full well the cost to the patient and the NHS. A report by Diabetes UK in 2014 estimated that the NHS’ annual spend on diabetes was approximately 10% of the NHS budget and would reach £16.9 billion by 2035/36. It also concluded that almost 4/5ths of the NHS diabetes spend was directed to treating diabetic complications that in many cases could have been prevented.
We recently held a webinar focussing on the management of lower limb complications in diabetic patients, across primary and secondary care. We were privileged to be joined by, amongst others, by Nicola Mottolini, Clinical Fellow in Diabetes at NHS Resolution, who spoke about her thematic analysis of claims in this specialist area, and the her report is due for publication shortly.
Following the webinar we also took the opportunity to catch up with another one of our speakers – Professor Bruce Braithwaite, Consultant Vascular Surgeon and Expert Witness to explore the topic further. We are pleased to be able to provide his expert insight to you here:
Q: During the webinar, you introduced the concept of a diabetic ‘foot attack’. Can you explain what this is?
A: So most people are familiar with the idea of a heart attack or a stroke – they are emergency conditions which require more blood going to the organ, whether that’s the heart or the brain. A ‘foot attack’ is when a person with diabetes has ulceration and also possibly added infection affecting the foot. These medical emergencies could start as bruises, blisters, hot spots, or cuts which instead of getting better, spread rapidly affecting the whole foot or more. Sadly, this often leads to the patient requiring an amputation of the foot/leg.
Q: Why are they difficult to recognise?
A: One of the real difficulties is that the foot can look red and warm as though it has blood going to it. What is actually happening though, is because there isn’t enough blood going to the foot, the small blood vessels try to dilate to suck as much blood into the foot as possible. 50% of patients with a diabetic foot ulcer will also have peripheral arterial disease and that needs to be appreciated by the clinicians examining the foot and the ankle pulses need to be checked carefully.
Q: So how does the peripheral arterial disease affect healing?
A: In order for a foot to survive when it has an injury, such as trauma or an infection, you have to have blood flowing into one of the arteries into the foot. In a patient with normal arteries, that patient will have easily palpable ankle pulses and good in line flow of blood to the foot. In patients who have peripheral arterial disease, their arteries have become blocked by a condition called atherosclerosis or hardening of the arteries. This blocks the pathways to the foot so that antibiotics have to travel further to reach the foot, it can take longer and by the time they reach the foot, they may not be in sufficient concentrations or may not be in time to heal the trauma. This means that ulcers can worsen or fail to heal and sadly, this often leads to amputations.
Q: And what do vascular surgeons do?
A: If possible we put in bypass grafts to get around the blockages or undertake angioplasty to restore the in-line blood flow to the foot. Unfortunately the natural history of the patient’s diabetes means that a patient may not have adequate blood supply to the arteries around the foot arch so that even with treatment, an amputation is inevitable.
Q: Why is this an emergency?
A: All the evidence is that we need to restore a pulse at the ankle and get blood into one of the arteries that lead to the damage where the ulcer is. If a patient doesn’t have a palpable foot pulse then they must be referred to secondary care the same day so that their arterial supply can be assessed and hopefully restored. The intervention needs to happen quickly and guidelines suggest this should take place within 5 days of admission.
Q: What is needed in primary care?
A: A good examination of foot pulses and a prompt referral to secondary care. Local foot care clinics and services across the country are patchy. Every CCG and new ICS should ensure that there are adequate provision of foot care services for these patients. The rates of amputations across the country vary considerably and the cost to both the patient and the NHS is enormous.
The advice from Professor Braithwaite is simple – a ‘foot attack’ is a medical emergency requiring prompt treatment in secondary care. This means there needs to be adequate provision of foot care services for diabetic patients in primary care so that the condition is recognised, and referral is made promptly. Each avoidable amputation represents a tragedy for patients and their families, and is associated with inevitable additional cost to the NHS.
For further information, please contact:
Joanne Hughes, Partner, Hill Dickinson