Rest pain

BACKGROUND: A 54-year-old man, Mr N, attends his GP surgery complaining of pain in his left calf and toes. The patient is obese and a smoker and suffers from hypertension. He is seen by Dr D who notes in the history that the pain began three days ago and is worse in bed at night. Dr D examines the foot and finds it cool to touch and describes the colour as “slightly dusky”. She also notes that peripheral pulses are evident on palpation. The GP refers the patient to a vascular clinic and in the referral letter asks for an urgent appointment.

Mr N re-attends the surgery a few days later and this time is seen by Dr C. The consultation is described as a “review appointment”. The GP notes again pain in the left leg and foot. On examination he finds reduced peripheral pulses but adequate capillary return no different from the right leg. Dr C questions whether the pain is more neuropathic than ischaemic. He prescribes the analgesic dihydrocodeine and instructs Mr N to return if there is no improvement.

Four days later Mr N phones the surgery for an emergency appointment, with intense pain in his left heel. A third GP – Dr B – examines the patient. He notes that the foot is cyanosed with poor capillary return. He forms the opinion that this is due to “poor circulation” and notes the request for referral made by Dr D. He arranges for a review in two days and prescribes ibuprofen.

Having missed a week of work Mr N returns to the surgery and sees Dr C again. The patient is now complaining of knee pain with irritated skin down the leg. He has been using Sudocrem but to no avail. The patient refuses to remove his shoe saying the problem is his “leg not his foot”. On examination the GP notes thin-walled blisters on the leg and mentions the possibility of pemphigus. He advises Mr N to keep the skin clean and to continue with the Sudocrem if the blisters burst. A referral is made to a dermatologist. No mention is made of any vascular problem in this consultation.

Two days before his hospital appointment Mr N returns to the surgery worried that the skin condition on his leg has become infected. He is seen this time by Dr D – the GP he first consulted with. Dr D records that the patient has a leg ulcer that is oozing profusely and looks infected. She prescribes an antibiotic and sends him to the practice nurse to have the leg dressed. The nurse records that the leg is in “terrible shape”. Mr N again refuses to remove his shoes but the nurse notes that his socks are soaking wet and that there is a strong smell.

Three weeks after his first appointment, Mr N is seen by a vascular surgeon at a hospital outpatient clinic. He notes that the patient has rest pain and gangrene in the left foot. The leg is blistered and ulcerated below the knee with large patches of non-viable tissue. A duplex scan shows that the entire arterial tree is occluded in the lower left leg. The surgeon is unsure of the aetiology but suspects a ruptured plaque. The only option at this stage is above-knee amputation. The surgery is carried out with no complications and Mr N is discharged five days later.

ANALYSIS/OUTCOME: Six months later a letter of claim for clinical negligence is received by the practice from solicitors acting on behalf of Mr N. It alleges a failure in duty of care in not realising that the patient’s blistered leg was due to ischaemia. Emergency hospital admission would have avoided the need for amputation.

MDDUS acting on behalf of its GP members commissions a report from an expert in primary care. The expert offers the opinion that Dr D was correct in making an urgent referral to the vascular clinic – but an immediate referral would have been more prudent. Checking the patient records the expert also discovers that Dr D’s referral letter was not typed and sent until six days after the initial consultation. This is clearly poor practice management.

The expert is also critical of the other doctors’ actions. In particular Dr C failed to note the connection between the patient’s skin condition and the potential ischaemia identified in the notes and earlier examination.

Considering the final consultation before Mr N attended hospital, the expert is critical of Dr D’s decision not to have the patient admitted to hospital immediately given the serious state of his leg.

The expert advises that there was a collective failure on the part of all the doctors involved and a serious lack of continuity of care. An additional report on causation by an expert in vascular surgery confirms that had immediate action been taken in the case Mr N would have had a reasonable chance of avoiding amputation.

MDDUS lawyers and advisers agree with our GP members to settle the case for a reasonable sum.

KEY POINTS

• Ensure practice systems prioritise urgent referrals and any delays are flagged.
• Examine how a lack of continuity of care in your practice might compromise patient safety.