Ischaemia in the toes

The scene

A diabetic patient presented to her GP with blisters, ulcers and bilateral ankle oedema in the summer of 2006. The GP, a member of the MDU, examined the patient and diagnosed an adverse reaction to the drugs she was taking for hypertension and diabetes.

At the end of that year, the patient developed cellulitis on her left shin and in January 2007 the GP once again took a history and examined the patient's pulses in her left and right legs. It was found that she had absent foot pulses and for over a year had been suffering from pain in both calves after walking. Our member referred her to the vascular department of the local hospital, but she did not attend the appointment.

Three months later, the cellulitis had spread to the patient's big toe and she also had an ingrowing toenail that was beginning to turn black. She was admitted to hospital where it was noted that the tip of her right big toe was ischaemic. Subsequently, the patient had her big toe amputated, and the following month underwent a further amputation - this time of her second toe.

A letter of claim was sent to the GP alleging that our member was negligent when the patient presented with blisters, ulcers and bilateral ankle oedema in July 2006, having failed to address the possibility that these symptoms were caused by peripheral vascular disease.
It was contended that the GP should have noticed the absent pulses in the patient's foot in July 2006 rather than January 2007 and should have referred her to the vascular department at the hospital sooner. This would have meant more prompt treatment, and the patient would have avoided the amputation of her toes.

The outcome


The MDU instructed a GP expert to give an opinion on the standard of care provided by the GP member. The GP expert pointed out that although the letter of claim had described the claimant as a non-insulin dependent diabetic, she had in fact been dependent on insulin for three years.
The hospital records revealed out patient diabetic clinic follow-up from 1990 onwards, including during the period giving rise to the complaint. The expert pointed out that the hospital care would have included monitoring all aspects of diabetes.
Although annual reviews were mentioned within the letter of claim and the GP computerised records, it was evident that the patient had attended the hospital on at least a twice-yearly basis for monitoring of diabetes. In effect, the claimant's care was under the auspices of the local hospital diabetic clinic, and the protocol for care would be the responsibility of that clinic.

The expert said that whenever the GP had seen the patient, his actions had been entirely appropriate. For example, he had referred the patient to the district nurses for leg ulcer dressings on numerous occasions, had treated her for a foot ulcer and had referred her to a consultant ophthalmologist when she had complained of visual symptoms.

He had also identified an absence of foot pulses in early 2007 and had referred the patient for specialist vascular surgical opinion in relation to calf pains on walking but she had failed to attend this appointment. The expert said the GP's case notes were of the highest order, and that at no stage could the GP be found wanting in his care of the patient.

On the basis of the expert's report, the MDU denied liability in the response to the letter of claim. It was pointed out that the patient's diabetic care had been in the hands of the local hospital, that the patient had missed appointments and that the GP member's care (and record keeping) had been beyond reproach. The claim was subsequently dropped.

This page was correct at publication on 17/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.