Untreated diabetes

BACKGROUND: Mrs G is a 48-year-old bank teller and attends her GP surgery complaining of swollen ankles. She weighs 15 stone and suffers from hypertension. The patient sees Dr W who notes ankle swelling with bilateral pitting oedema. Her BP is 180/110. The GP issues a prescription for furosemide in addition to her regular medication for hypertension. He requests Mrs G re-attend the surgery for blood tests.

A week later Mrs G sees the practice nurse who takes blood and also performs a urine dipstick test. Traces of blood and glucose are found in her urine. The blood test results later show a normal full blood count, thyroid, liver and renal function but her blood sugar is raised at 15.8 mmol/L.

Mrs G returns to the surgery to discuss the results with Dr W and is told that she may have diabetes. The GP advises the patient to provide a fasting blood sample. Mrs G arranges an appointment but the surgery later calls to cancel because the practice nurse is not available on that day. The receptionist says that the practice will contact her again to re-book a new appointment. Mrs G hears no more from the surgery and assumes the matter is not important.

Two years later Mrs G has begun to feel increasingly lethargic. She also notices some hard skin under her right great toe. The skin becomes loose in the shower and she removes it with some bleeding. She applies a plaster and Germolene but after a week it becomes obvious the toe is not healing well. Mrs G attends Dr W at the surgery. He examines her toe and prescribes an antibiotic. He also again requests the patient provide a fasting blood sample.

Mrs G sees the practice nurse who takes the bloods. She comments: "So I see you’re a diabetic." The patient replies that she has never been told that for certain. The blood test later reveals a fasting glucose of 20.2 mmol/L and a raised HbA1c of 13.8.

Two days later Mrs G sees Dr W who informs her that she is a diabetic. He prescribes metformin and also further antibiotics for her toe – which he examines but without removing the dressings. An appointment is made for Mrs G to see the diabetic nurse but a mix-up in scheduling means that the nurse has inadequate time to provide a full diabetic induction. The nurse is also unable to examine the patient’s feet. Mrs G again mentions the infection in her foot. The nurse tells her to persist with the antibiotics and see Dr W if there is no improvement.

A week later Mrs G returns to the surgery. Her toe has turned black and there is now a smell. Dr W asks her to remove her shoe and also notes the smell. He does not remove the dressings but refers the patient immediately to A&E. Later in hospital she undergoes amputation of her right great toe. She is commenced on insulin and IV antibiotics. The surgical wound is slow to heal and Mrs G later develops ulceration under both feet.

Four months later the practice receives a claim of damages for medical negligence in the delayed diagnosis of Mrs G’s diabetes leading to the loss of her toe and further diabetic neuropathy.

ANALYSIS/OUTCOME: MDDUS, acting for Dr W, commissions a report from a primary care physician with expertise in diabetes. He is supportive of the GP’s initial management of the patient in arranging for a fasting blood test to confirm the suspicion of diabetes but he finds fault in the obvious system error in failing to rearrange the cancelled appointment. This led to a delay of two years in commencing management of the patient’s diabetes.

The expert is also critical of Dr W’s actions in not properly examining Mrs G’s toe upon confirming her diagnosis of diabetes. In addition, fault is found in the failure of the diabetic nurse to prioritise examination of the patient’s toe considering her longstanding uncontrolled diabetes.

In terms of causation it is obvious that the delayed management of Mrs G’s diabetes contributed to the eventual loss of her toe and subsequent complications. MDDUS solicitors in discussion with Dr W agree to settle the case out of court.

KEY POINTS

• Ensure practice systems flag the need for follow-up on all abnormal results.
• Follow-up missed or cancelled appointments – especially for crucial tests.
• Be wary of all foot infections and injuries in diabetics.