Litigation and the diabetic foot

Introduction

People with diabetes face a greatly increased likelihood of lower limb amputation,1 an extremely distressing event often followed by denial and grief over the loss of body image and function.2 Anger may be directed at those health care professionals who were involved in the care of the affected limb and who are sometimes blamed for ‘causing the amputation’. While this quite frequently felt need to allocate blame is not a new phenomenon, it now occurs in the context of an increasingly litigation-prone climate. Claims against vascular surgeons, for example, were shown to have risen four-fold in the period 1990–95 compared with the period 1985–90.3 It is clear that lawsuits are filed not just for financial reasons but also because people feel abandoned and aggrieved.4

Podiatrists are often blamed when a person with diabetes undergoes amputation. Although many complaints are settled locally and quickly, there seems to be an increasing climate of litigation against podiatrists, who may be blamed for causing ulcers, gangrene or amputation.5

An understanding of the work of podiatrists is frequently poor among patients and other health care practitioners, and consequently podiatrists may be held directly responsible for the amputation due to ignorance about their scope of practice. Community podiatrists, who often work in isolation both personally and professionally, appear to be especially at risk of accusations that they directly caused amputations.

We describe two cases of recent complaints against podiatrists, in which we have been asked to arbitrate, where diabetic foot problems led to amputation. We discuss the reasons why complaints were made, some of the issues which need to be addressed if complaints are to be avoided and the ways in which patients can be helped to come to terms with loss of a body part. We believe that this is an increasingly important issue, not only for podiatrists but also for every diabetes team member.

Case 1

A 62-year-old man with type 1 diabetes of 48 years' duration had diabetic retinopathy with recent loss of vision in one eye. He also had neuroischaemic feet, although neither the patient himself nor the primary care team caring for him appeared to be aware of this fact. He was referred to a community podiatrist by a practice nurse because she had noted thickening and discolouration of his toenails. The original referral, however, went missing. A further hand written referral was made 23 days later after a telephone request by the patient, but only gave the patient's details with no indication of the clinical nature of the problem or its urgency.

The podiatrist saw the patient within two weeks of the second referral. It was the first time he had met the patient. He diagnosed tissue breakdown with pus under thickened nails which needed immediate draining to prevent spread of infection. This involved cutting back the overlying area of the nail plate – a procedure which can sometimes be painful. Local anaesthetic is not usually given, however, since the presence of fluid under the nail lifts the nail plate which can be cut back with less discomfort to the patient than the pain of undergoing a ring block. Furthermore, where the collection of pus under the nail is painful, cutting the plate back with drainage usually relieves pain very quickly.

Following treatment, the podiatrist recommended that the patient visit his general practitioner (GP) for antibiotic treatment and subsequent dressing by the practice nurse. The GP's surgery was next door to the podiatry clinic. The podiatrist did not arrange a routine follow-up appointment but asked the patient to report back to his GP or to himself if there was any sign of deterioration. The podiatrist said that he had sent a report to the patient's GP, but this has never been found and the podiatrist did not have a copy of his letter.

The patient did not report to his GP for antibiotics. The foot developed ascending infection and the patient underwent a below knee amputation, which was performed by a general surgeon whom he saw privately. The patient complained that the podiatrist had not provided adequate care, that he had been exposed to a severely painful surgical procedure (the cutting back of the nails) without explanation or anaesthetic and, furthermore, that the podiatrist had been responsible for causing his foot problems and subsequent leg amputation.

An independent review panel which was convened to hear the patient's complaints decided that the cutting back of the nails was an appropriate treatment but criticised failures of communication between podiatrist, GP and practice nurse. The review panel gave guidance about the importance of careful record keeping and storing and ways in which improvements in communications with patients could be made. The panel also advised the primary care trust (PCT), for whom the podiatrist worked, to establish written guidelines for the treatment, referral and follow-up of diabetic foot patients.

Case 2

A 53-year-old man with type 2 diabetes of eight years' duration developed a neuropathic foot ulcer which healed in three months. Following this he had no contact with the local podiatry service for nine months, but then telephoned a community podiatrist complaining of a new foot ulcer. She advised him over the phone to see his GP for antibiotics. She also saw him herself the same day, when she learned that he had not in fact visited the GP following his telephone call to her. His reason for this was ‘it takes a week to get an appointment’. He had also visited the accident and emergency department of a local hospital two days previously, but had not waited to be seen. The podiatrist cleaned, debrided and dressed the ulcer and offered frequent appointments over the next three months, during which period two other ulcers on the patient's feet developed and healed. Although the primary ulcer failed to heal, the podiatrist recorded that she could find no clinical evidence of infection and the patient was also seen twice by other podiatrists, on single occasions, neither of whom felt the need for referral. The patient's memory of this time, however, was that the foot was swollen and that his partner had commented on the fact that the foot was malodorous.

Three months later the foot suddenly deteriorated. The podiatrist obtained an X-ray referral from the local consultant diabetologist, although the patient felt that this was only because he had repeatedly asked her to organise this. He commented that the podiatrist neither knew how to organise an X-ray nor had ever done so before. The diabetologist saw the X-ray and arranged to admit the patient to hospital the same day. The toe required amputation. Four months after the amputation the patient had received no podiatry follow-up. He complained bitterly that he had lost his toe because of poor podiatry care and failure to refer him to a specialist centre.

A complaints panel which met following the patient's request for an independent review, after local resolution had failed, could find no fault in the timing, regularity and appropriateness of the treatment offered by the podiatrist, but was concerned that she was working in a very isolated manner. She was unsure about the mechanism for obtaining microbiology and X-rays of a toe and rarely saw the consultant diabetologist or other members of the diabetes team. There were no mechanisms for ensuring follow-up appointments for high-risk patients and the podiatry service depended on the patients themselves making further appointments. There was no system for contacting or recalling high-risk diabetic patients who failed to attend for an appointment. The panel made recommendations to the PCT relating to community podiatrists working alone in the care of people with diabetes (Table 1).

Factors contributing to complaints and litigation

The anger which diabetic patients may quite commonly feel following lower extremity amputation can lead to complaints and litigation directed at those perceived to be at fault. All health care professionals are at risk of being complained about (whether justly or unjustly) but podiatrists appear to be especially and increasingly at risk in this situation.5

Problems are exacerbated by the fact that diabetic feet can deteriorate with alarming rapidity, sometimes within a few hours of a break in the skin appearing. Patients with neuropathy or neuroischaemia may be unable to mount the inflammatory response necessary to achieve healing and prevent infection. The cardinal signs – redness, warmth, swelling, pain and loss of function – may be absent or greatly diminished.9 Many diabetic patients with foot problems are immunocompromised and do not become pyrexial or raise their white cell count even in the presence of limb-threatening infection.10, 11 Furthermore, many patients with foot ulceration also have retinopathy and are unable to see their feet clearly. Patients may thus be unaware that they have a foot problem, or that the condition of the foot is deteriorating.12 They may be unaware of the practical implications of protective sensation loss and the dangers of neuropathy and ischaemia, even though the potential problems may have been discussed with them many times during their diabetic life and diabetes foot care advice reinforced regularly.13 This failure on the part of people with diabetes to comprehend how diabetic foot problems develop or to perceive that they are at risk may be due to a genuine lack of understanding, but is very often associated with a profound sense of denial – which is well known to be a major factor in many patients who come to grief with diabetic foot problems.14

Part of the ‘grieving process’ following a serious illness, amputation or death involves anger and denial, as already discussed, and a need to allocate blame. Patients may feel safer if they can believe their problem was a ‘one off’ disaster which was the fault of someone else. This may reflect, perhaps, an unconscious inability to admit that they themselves may have had a part to play in avoiding the outcome. They thereby deny responsibility for self-care, as well as the possibility that they may still be at risk of further problems, including the potential loss of the remaining toes or limb.

Podiatrists often work in isolation, without support from members of the multidisciplinary team. Access to microbiology and X-rays may be difficult for podiatrists who are community based. Knowledge of the scope of practice of podiatrists is poor, as already stated, even among other health care practitioners, who frequently do not appreciate the importance of sharp debridement in the prevention, detection and management of diabetic foot ulcers.15 Furthermore, neuropathy has very profound effects on diabetic patients: they do not perceive their feet as a problem when they are not painful, and lack of touch gives them a very abnormal view of the ‘boundaries of self’. In other words, they may not feel responsible for the feet they cannot feel,16 and they will not feel pain or unpleasant symptoms until foot problems are very advanced. In a symptom-led health care system, this failure to complain or report foot problems because they are not painful frequently leads to disaster.

Prevention of dissatisfaction and complaint

There are ways of reducing complaints, however. People with diabetes are entitled to good foot care and all podiatrists involved in the care of high-risk people with diabetes should be state registered.17 Wherever possible, podiatrists should acquire additional training in the management of the diabetic foot, such as completing the Postgraduate Diabetes Foot Module of the UK Society of Chiropodists and Podiatrists. Podiatrists should establish contact with their local multidisciplinary diabetes foot clinic and, if such a clinic does not exist, they should apply pressure on local trusts to set one up, in accordance with the proposals of the National Service Framework for Diabetes.

Identification of at-risk patients and accurate assessment of any diabetic foot problem are vital,18 and this may include asking for an early second opinion from other colleagues.

Explaining to the patient in clear, simple language what needs to be done is essential, and a knowledge of the ‘understanding gap’ is important.19-22 Verbal communication is a potential minefield and, in our experience, verbal communication problems are a significant cause of NHS complaints. There is often a different perception of what was said, what was meant, what was heard and what was understood. Patients may be in a highly stressed state at the time of consultation, making them potentially much less receptive to even simple explanation and, therefore, understanding.

It is not acceptable in this electronic age to depend on the telephone or verbal messages carried by the patient, when communicating with the GP about the need for an antibiotic prescription. Communicating with a patient via a simple ‘what to do now’ pad is a useful idea: tick box instructions such as ‘rest completely’, ‘see GP for antibiotics’, ‘toes re-dressed every two days’ can be given to the patient to take away with them to reinforce verbal advice.

Community podiatrists should not ‘hold on’ to any diabetic patient with a foot ulcer for too long, but should seek help early. The recently reviewed, evidence-based guidelines for the management of patients with type 2 diabetes specify that patients with a new ulcer, discolouration or pain in a foot should be referred to a specialist team within 24 hours – reinforcing the view that offering a rapid access, same day emergency service to people with diabetes with foot problems is essential. Documenting what has been done and why is basic good professional practice. Colour photographs taken with a digital camera can be extremely helpful not only in providing a clinical record but also, should the need arise, in providing medico-legal evidence as to the state of the foot at a certain time – as occurred in Case 1 described above.

Above all, it is essential that PCTs work together with diabetes specialist teams to develop guidelines for diabetic foot management and ensure that these are understood and adhered to by all those with responsibility for caring for people with diabetes.

The role of the diabetes team

The loss of a limb has been compared to the loss of a spouse.23 The clear visual memories of the lost person, and the strong sense of their persisting presence, is manifest in the amputee as the phantom limb. The anxiety, depression and sexual problems which may develop are often related not only to the type of loss (leg versus toe in the above examples), but also to the personal vulnerability of each individual patient. In other words, the pre-morbid personality of a patient influences their ability to cope with such a situation and podiatrists and other health care professionals should be aware that amputees with a long-standing tendency to anxiety and depression (‘sensitisers’) have been shown to cope less well24 – as do those (usually always men) who show little evidence of distress at the time of amputation (‘avoiders’).25, 27

Problems following amputation can be prevented by information, advice and emotional support prior to surgery.28 Patients should be warned that a phantom limb, which may be painful, might persist for a while. Early recognition of problems is important in reducing possible long-term psychological morbidity. Every patient should be asked how they feel following amputation and should be encouraged to discuss problems.2 Involving the family in this is helpful to both. Meeting other amputees can reassure patients that it is possible to live with disability.

Conclusions

A large number of patients with diabetes are managed in the community and this situation is likely to continue and the numbers increase. People with diabetes foot problems require a multidisciplinary team including consultant diabetologist, diabetes podiatrist, diabetes specialist nurse and orthotist – with access to vascular surgeons and interventional radiologists as needed.9 The need for urgent intervention and follow-up of high-risk cases is accepted as normal working practice.29-31 It is unacceptable for high-risk diabetic patients to be treated in isolation. PCTs cannot offer adequate care to diabetic foot patients without access to combined diabetes specialist foot care clinics.

Clear referral guidelines and care pathways should be developed, understood and adhered to and should include the sort of approach shown in Table 2.

By understanding the reasons which lead diabetic patients smitten with the tragedy of amputation to complain and undertake litigation, we believe a service should be better equipped to minimise such complaint. The development of agreed guidelines and care pathways should result in a much improved podiatry service and reduce dissatisfaction aimed against diabetes carers, among whom community podiatrists appear to be particularly at risk. Most importantly, by providing support and counselling aimed at preventing and recognising the psychological morbidity of this condition, diabetes teams can give better care to patients at the profound point of surgical amputation.