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NHS Resolution undertook a retrospective review of closed claims between 2013/14 and 2018/19 listed on their claims management system and published its ndings in June 2022. These included claims where both liabilities were accepted or denied by the various NHS trusts, although no specic information was provided. Of the 92 claims analysed, the authors found that individuals were overwhelmingly male (>75%) and 78% were over the age of 50years. Claims around major amputation accounted for the highest proportion (55/92, 60%) followed by minor amputation (30/92, 33%). The review highlighted certain recurrent themes, one or all of which could indepen­dently contribute to suboptimal outcome in diabetic foot disease (Box 18.1).

Patients did not show sufcient evidence of healing of foot ulcers prior to discharge from hospital.

It identied that there were signicant challenges in risk stratication and front­line foot protection with 91% of the individuals not having their foot-ulcer risk status documented in the community, leading to a pre-morbidity capture of only 5% as high risk for foot ulceration (85% were true high-risk in the sample). Once a foot problem was identied, there were signicant delays in accessing specialist foot services as recommended by NICE NG19 with 64% not having regular specialist team input and 52% never having received multidisciplinary foot team (MDfT) input at any stage. Once referred to a specialist service, there was a paucity in the quality of standard care provided with lack of quality, regular debridement (70%), wound microbiology assessment (50% did not microbiology sample sent at any stage) and delays in performing radiological investigations—indeed, 34% did not have an x-ray at any stage. Perhaps the most important concerning factor was that vascular assessment in these complex cases were brief, potentially inaccurate (51% of pulse palpation readings were deemed incorrect), missed (33% where known vascular history was ignored) and delayed. Individuals waited an average of 90days between identication of tissue loss and vascular investigations and 50days between investigations and revascularisation. Furthermore, the review identied a severe lack in quality ofoading provision (58% no ofoading, 11% saw an orthotist) and in addition to paucity of psycho-social support. Another recurrent theme was the lack of standardised access to hospital admissions, indeed the review identied 25 different methods of hospitalisation. While anecdotally the number of claims related to Charcot neuroarthropathy and its sequelae are increasing, this was perhaps under­recognised within the thematic review.

The Court of Protection has issued guidance about when best interests decisions should be referred to the court for a decision to be made by a judge [14]. If the deci­sion concerns life-sustaining treatment, and it is nely balanced, or there is a differ­ence of medical opinion, a lack of agreement about what should happen, or a potential conict of interest, then an application must be made to the court. This would apply to decisions about amputation where the clinical view is that without amputation, the patient is likely to die. Even if the decision does not concern life­sustaining treatment, then an application to the court may be required if any of those factors is present [15]. If providing treatment would require the patient to be sedated or physically restrained in order to prevent them objecting, then court authorisation is extremely likely to be needed. A brief overview of the process to be followed is outlined below (Fig.18.1).

The death was unnatural.

to 30days since CVOID-19), nor after death.

Death occurred during surgery or recovery from anaesthetic. It is normal to discuss cases that occur with 30days of surgery or an invasive procedure, even when the circumstances do not cause concern.

It is normal to discuss all deaths occurring in the Accident and Emergency Department, and any deaths within 24h of admission with the Coroners ofce.

Clinical practice often imposes multiple barriers to good practice. The workload for clinicians is constantly increasing, and there are signicant disruptions and tempo­ral evolutions in the care process pathway that we practice in. Furthermore, many regions in the United Kingdom do not have robust Multidisciplinary Diabetic Foot Teams (MDFT) [25] and exhibit wide variation in adopting NICE guidance and best practice algorithms [26] which are likely to impact on clinical outcomes and the risk of potential litigation. It is therefore crucial to develop a systemic wide approach in addition to clinician level behaviour to reduce the risk of litigation (Fig.18.4). Decisions on the management of diabetic foot disease must be done through a MDFT (‘no one person or speciality can manage the diabetic foot’), and at a system level, provider services should develop pathways that adopt this and provide care within the time frame recommended in the guidance documents. Timing is key to outcomes in diabetic foot disease, to prevent or contain limb threatening problems [26, 27], and all reasonable efforts should be made to ensure this. MDFTs should clearly document their ndings, decisions and rationale while ensuring quality fol­low- up is put in place. Such units should also aim to demonstrate good clinical practice through a rened clinical governance structure (regular service and adverse