NHS Resolution has published an important report on lower limb claims (the majority of which involving amputations) arising from diabetes in England, with the aim of improving patient care and reducing the number of claims being made.
As Professor Mike Edmonds, Consultant Diabetologist at King's College Hospital, notes in the foreword, “This report highlights shortcomings in diabetes foot care in England…There
must be learning from the diabetes-related lower limb amputations analysed in this report and a thorough appreciation of why they occurred. Amputation is not an inevitable progression of lower limb pathology. The report makes recommendations to improve patient care and proposes certain standards which should be put into practice and regularly audited. By this means, it is hoped that the preventable loss of limbs due to diabetes be reduced and the trend to the increasing number of major amputations in England be reversed.”
Ninety-two claims were reviewed for the report, all involving patients who had a diagnosis of diabetes. The majority of claims involved patients who had suffered with a diabetic foot ulcer (DFU) and went on to undergo a major lower limb amputation. In this article, we look at the key themes and recommendations arising from the review of these cases.
Themes
Review of the claims highlighted variation between different services in the way diabetic foot care is provided, and inconsistencies in care across stages of the patient pathway. This was reflected in the way in which diabetic foot disease was described and managed, with different clinicians providing different details, or reaching a different diagnosis for the same pathology, and using inconsistent assessments to reach this diagnosis.
In the claims reviewed, patients deteriorated while waiting for interventions or reviews. The report states that this deterioration, and the overall severity of the situation, was often not recognised, and the management plan was not adapted or expedited.
The report states that delays were frequent, and there was a lack of urgency behind the care provided. The absence of timely provision of care, coordination of management, and recognition of inconsistencies were, the report concludes, likely the result of a lack of clarity as to which clinician or team was directing care and making management decisions. The claims showed that having multiple disciplines involved in a patient’s care did not necessarily result in integrated, multidisciplinary team working. The report highlights the importance of MDFT oversight, rather than just input, in being able to provide effective care to patients with these complex needs.
The themes identified in the claims were apparent at every stage of the patient journey, and across all settings from primary care through to tertiary services.
Recommendations
The report provides the following seven recommendations (at both local and national levels):
1. Education and Training
The report states that “With the correct education and training, clinicians will understand why lower limb amputations are not inevitable, even with advanced pathology, and at every stage of care provision there is the opportunity to influence patient outcomes”.
2. Pathways and the provision of consistent services
The report states that “Pathology should first be identified consistently, allowing clinicians to then follow the appropriate guidance and pathways. A designated pathway lead should work to identify any barriers to streamlined care between primary, community, acute and inpatient services, allowing patients to move rapidly and seamlessly through the entire footcare pathway without delay. To ensure pathways facilitate the delivery of consistent care, the structure and remit of the services they feed into should also be well defined and standardised”.
3. Biomechanics and offloading (pressure relief)
The report states that “Assessing lower limb biomechanics accurately, acting on the results of these assessments, and redistributing pressure from anatomical areas that are at risk of, or have active pathology is crucial to the successful management of any diabetic lower limb complications”.
4. Commissioning of services
The report states that “One identifiable governing team should have responsibility for and be able to review and audit the entire patient journey through primary care to tertiary services”.
5. Public health campaign
The report states that “A national public health campaign will increase awareness of diabetic foot disease and the impact it has on patients and their family and friends. This increased awareness should prompt an increased uptake of preventative measures and help to empower patients with active foot pathology”.
6. Leadership and workforce
The report states that “Ensuring that positions of leadership, influence and accountability exist, that are appropriately banded, may not only improve service provision but help to ensure there are routes for career progression for clinicians”.
7. Participation in the NDFA and local service audits
The report states that “In order to undertake workforce planning and to provide a service that meets the needs of its patients, there must be accurate recording and auditing of the service”.
Conclusion
By analysing these particular clinical negligence claims, NHS Resolution has identified a number of themes and made a number of recommendations that should, when implemented, contribute significantly to improving patient safety. Not only this, such measures should also help to reduce the NHS’s expenditure on clinical negligence claims.
A link to the reports can be found here.
