Limb threatening ischaemia

The scene

A patient with a long history of ischaemic heart disease, renal failure and diabetes presented to his GP with symptoms of chronic peripheral vascular disease. Soon after the consultation he experienced worsening symptoms and saw various other GPs, and was referred for an MRI scan for his back pain and to vascular surgeons for his peripheral vascular disease.

Six weeks after the initial appointment, the patient saw a GP at an out of hours clinic with persistent symptoms. After examining the patient's right foot, this GP – an MDU member – didn't believe it exhibited acute ischaemia. The GP prescribed analgesia for the patient's back pain and advised him to return to his own GP, which he did.

Ten days later, the patient attended hospital with an acute ischaemic right foot, and an occlusion of his popliteal artery was identified and successfully treated. Precautionary leg fasciotomies were also performed and revised a week later, but these were slow to heal and were complicated by infection that needed plastic surgery to graft the wounds.

The patient instructed solicitors to issue a letter of claim alleging that the MDU member should have arranged urgent admission to hospital for limb threatening ischaemia.

The member was able to recall the consultation in detail and his records supporting his actions were full and clear.

MDU response

The member was able to recall the consultation in detail and his records supporting his actions were full and clear.

The MDU obtained an independent expert opinion from a GP. The expert's view was that the patient had presented with symptoms arising from his long-standing back pain and chronic peripheral vascular disease, and that there was nothing about his presentation that warranted an urgent referral to hospital for an acute ischaemic limb on that day.

The GP expert also said it was reasonable for the member to provide analgesia, and in the absence of an acute ischaemic event, to advise the claimant to see his usual GP for management of his chronic peripheral vascular disease.

Causation advice was obtained from a vascular surgeon expert, who said she would only have expected an urgent telephone referral to be made if the patient was thought to have immediate limb threatening ischaemia following an acute deterioration, which she didn't believe was the case when the MDU GP saw the patient.

She also believed it was very doubtful that the patient could have presented with immediate limb threatening ischaemia when he saw the MDU GP; if so, he would
have been hospitalised much earlier. 

A detailed response to the letter of claim was drafted, making clear that this was an out of hours consultation as well as the information that was available to the MDU member at the time. The response also expanded on the member's detailed note on the basis of her recollections of the consultation, as well as confirming the supportive expert advice obtained on both breach of duty and causation. As a result, the patient subsequently discontinued their claim against the MDU member.

This page was correct at publication on 14/03/2017. 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.


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