Case 10 Not a leg to stand on

Rashid Khan is a 73-year-old man with angina, type 2 diabetes and diabetic nephropathy who has been living alone since the death of his wife two years ago. His daughter has become concerned that he is becoming less mobile and is having difficulty looking after himself. She calls in to see him and finds him to be mildly confused. She also notes that he has been incontinent of urine. The GP is asked to visit and he finds Mr Khan to have a temperature of 38.5 °C and he refers him to the acute medical take with a presumptive diagnosis of urinary infection.

It has been a very busy intake and Dr Jones, a medical consultant is triaging patients in a cubicle on the AMU. She takes a history from Mr Khan who denies much is wrong, but Dr Jones notes the continuing pyrexia and finds coarse crepitations at the right lung base. She asks for a chest X-ray and a urine dip, some electrolytes and blood cultures. Mr Khan’s right leg is bandaged and Dr Jones asks what the problem with the foot is and is told that there is an ulcer at the ankle which the district nurse has been dressing. Dr Jones does not take the dressing down but makes a note to do so later on the post take ward round.

Is this a reasonable course of action?

Two hours later Dr Jones reviews Mr Khan and looks at the chest X-ray which she feels shows some patchy changes at the right base and she commences oral co-amoxiclav. The blood tests she did show a creatinine of 190 mmol/l, the CRP is greater than 160 and the blood glucose is 13.7 mmol/l. The urine dip shows ++ protein but no leucocytes or nitrites. A diagnosis of pneumonia is made and Dr Jones asks the nursing staff to keep a close eye on the blood glucose and to take the dressings down that evening. Before this can be done a bed becomes available on one of the medical wards and Mr Khan is transferred.

At midday the next day the medical registrar, Dr Pandher looks in on Mr Khan who seems cheerful and his temperature is now 37.5 °C. The blood glucose remains around 14 mmol/l and no further action is taken. Dr Pandher leaves a note for the weekend cover team to ask them to review Mr Khan and ensure his diabetic control is adequate.

On Monday, Dr Jones and her team see Mr Khan again and Dr Jones is concerned that Mr Khan appears to have deteriorated. His temperature is still 38.0 °C and he is now unable to mobilize because he is weak and his right foot is mildly painful. Dr Jones takes the dressings on the foot down and is alarmed to find a very deep, foul smelling and necrotic wound on the heel which appears to involve the bone. She realizes that the dressing is the same one Mr Khan had when he was admitted four days earlier. An urgent MRI of the foot is arranged and the plastic surgery team are asked to come to advise. The scan confirms a diagnosis of osteomyelitis and a shard of glass is found in the wound. Despite two attempts at debridement and the use of broad spectrum antibiotics, it is not possible to salvage Mr Khan’s leg and 10 days after admission he undergoes a below knee amputation and after a further prolonged attempt at rehabilitation arrangements are made for him to sell his home and move to a nursing home.

Was this preventable?

Mr Khan’s daughter asks why the infection was not detected earlier and Dr Jones explains that she asked for the dressings to be taken down on the day of admission but a combination of pressure of work and the fact that Mr Khan was moved to the ward meant that the message did not get passed on. Dr Jones apologizes and acknowledges she should have done this herself in view of the clear history of diabetes with microvascular complications. On review of her notes they are found to be brief and do not show any record that she looked for signs of peripheral neuropathy or peripheral vascular disease. She felt she had made a diagnosis of pneumonia and did not look for further problems.

The family decide to seek compensation on the grounds that the delay in diagnosis affected the outcome and made amputation inevitable. If the infection had been picked up earlier he might have been spared the operation and could have been able to return home instead of having to pay for a nursing home.

Expert opinion

Most doctors practising acute medicine will readily relate to Dr Jones’ situation. She was doing the best of a bad job during a busy on-call and making brief triage assessments of the patients presenting to the medial take. Her assessments were not as thorough as they might have been but her purpose was triage not to undertake definitive clerking. Each stage of the delay to inspecting Mr Khan’s foot can easily be explained away but when taken together the result was catastrophic. Dr Jones’ error was inadequate handover – it is perfectly acceptable not to have taken down the dressings in the first hour or so of admission but failure to appreciate the potential severity of diabetic foot infection is a recurring theme in medico-legal cases.

Always examine what lies beneath dressings and difficult to remove clothing, especially where there is a high index of suspicion of infection.

Legal comment

Breach of duty will be difficult to defend in this civil clinical negligence claim. Dr Jones did not remove the dressing at the time of initial assessment. The request for nursing staff to take the dressing down appears to have been a verbal instruction as opposed to one documented in the healthcare records. Further time is lost over the weekend and the failure in the interim by the nursing team to review the dressing represents care which falls below acceptable standards. Mr Khan has been left with a foreign body in his foot whilst under the care of the medical team. The issue of causation will be the key ground for dispute in the civil claim. To what extent would the below knee amputation have been avoided if the dressings had been removed on the evening of admission and immediate treatment undertaken to remove the shard of glass, to debride and to prescribe broad spectrum antibiotics?

Expert evidence will be required as to whether the delay in assessment by the medical team has affected the outcome. This will be a high value claim with significant compensation given the impact on Mr Khan’s mobility, and the difference between prognosis had the below knee amputation been avoided. Future care is usually the most expensive part of a future damages claim. Providing nursing care and adaption of an existing home would not be as costly as nursing home fees and the impact of having to sell Mr Khan’s house. This case highlights the importance of clear documentation of communication of requests for actions to be taken between different parts of the healthcare multi-disciplinary team and to provide later evidence of clinical decision making, escalation and expectations. The defendant in the claim will be the NHS Trust on behalf of all its employees.

Review by the Trust’s clinical risk team for root causes should also include training/reflection by the medical and nursing staff involved on the failure to provide adequate care. Dr Jones’ actions are further impaired by a lack of documentation regarding her clinical examination and consideration of differential diagnoses. Depending on the expert evidence in regard to causation there may be grounds for obtaining a causation discount. If the expert advice is that even if the wound had been examined at initial admission and appropriate treatment instigated, there would have been no difference in outcome, this can be used as a basis, following meeting of experts, to negotiate a discounted settlement.

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