BACKGROUND Mrs H is 58 years old and has been a type 1 diabetic since childhood. Her control is moderate to poor and she is overweight. She attends her GP complaining of pain over the top of her right foot for a number of weeks with no history of trauma – but she has recently taken on a new job at a supermarket that involves spending more time on her feet. Paracetamol has helped to relieve the pain somewhat but it has “flared up” again in the last few days. The GP – Dr L – finds no obvious swelling

or deformity on examination and the tenderness seems to be localised to the tendons running over the dorsal surface of the foot. He concludes that Mrs H is most likely suffering from tendinitis. She is advised to use a topical NSAID gel with regular oral paracetamol and rest with supportive footwear. Dr L advises her to return in two weeks if the pain has not settled. Two months later Mrs H attends a

routine podiatry appointment and again complains of a sore foot. The podiatrist finds the arch of the foot (mid-tarsal joint) swollen and warm and notes crepitus on manipulation. She writes to the practice requesting a referral for an X-ray and blood tests to rule out the possibility of Charcot foot, in light of the patient’s pre-existing diabetes. The letter is delayed in reaching the GP practice and the X-ray later reveals moderate to severe degenerative changes in the foot.

18 / MDDUS INSIGHT / Q1 2019

A month later Mrs H attends the practice

diabetic nurse for a routine check and is given a copy of the X-ray to show the podiatrist at her next appointment in two weeks’ time. Here Mrs H complains that her foot is very sore and she has had to take time off work. Again the foot arch is found to be warm and swollen with crepitus on manipulation. The podiatrist writes to the practice to ask that Mrs H be referred urgently to the diabetic foot clinic. It takes another 10 days before that

referral is sent and a further 10 days before Mrs H is seen at an outpatient clinic. Here a pedal temperature difference greater than 2˚C is recorded alongside pain in an insensate foot, unilateral foot oedema and osseous deformity in the medial longitudinal arch. Diabetic Charcot arthropathy is diagnosed and an urgent CT scan is arranged. Mrs H is treated via an air cast boot and crutches. A few months later Dr L receives a letter of claim alleging clinical negligence in failing

KEY POINTS ●Record full history/examination findings and justification for treatment decisions. ●Ensure practice systems adequately track urgent referrals and pick up “red flag” symptoms.

to diagnose and refer Mrs H for suspected Charcot foot. It states that as a result the patient has been left with a forefoot deformity with splaying of the second and third toes. She is now unable to walk long distances (requiring a crutch and orthotic footwear) and has been permanently registered disabled.

ANALYSIS/OUTCOME MDDUS commissions an independent GP expert to review the case. Notes from the first and only consultation undertaken by Dr L record tenderness localised to tendons running over the dorsal surface of the foot. Dr L observes no obvious swelling/ deformity or redness/heat – nor any other signs indicative of Charcot arthropathy. The expert finds no specific reason why Mrs H should have been referred to the diabetic foot clinic at this stage and is not critical of the standard of care provided by Dr L. The expert does believe that there is an

issue with the 10-day delay by the practice in ensuring Mrs H was seen urgently by the diabetic foot clinic, as requested by the podiatrist. However, he recognises that this is not part of the allegations. A letter of response is sent by MDDUS on

behalf of Dr L denying breach of duty of care and causation (adverse consequences of that breach). Nothing more is heard from the claimant solicitors and the case is eventually closed.

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