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P. Vas and V. Butler-Cole KC
System-wide approach
• Integrate clinical pathways between
community and into hospital (MDfTclinics)
• Incorporate and adhere to NICE NG19
guidance
• Clear admission pathway
• Define links between vascular hubs and
spokes
• Regular clinical governance
• Participate in national audits, GRIFT
• Investigate complaints promptly, ensure
duty of Candour
• Maintain good communication for
complaints/queries.
Fig. 18.4 Reducing the risk of litigation: System-wide and individual level approaches. It is
important to remember that these two aspects are inter-linked
Individual level responsibilities
• Work in teams
• Maintain CPD and training
• Ensure documentation is clear, accurate
and legible
• Regular attendance at governance
meetings
• Participate in audit and clinical reflection
• Ensure quality communication–with
patient, carers and colleagues
• Engage with requests for response to
complaints, legal team queries
• When things go wrong, do not judge
incident reviews, reection), quality audit (local audit cycles; contribute to the
National Diabetes Foot Audit) and ensure safe pathways are designed between hubs
and their connected spokes. Adherence to guidelines, such the NICE NG19 for diabetic foot ulceration is very important and should be consistent between sites. At an
individual level, it is important to ensure that every decision or plan is carefully
explained to the patient and clearly documented at the time. Where a patient lacks
capacity to make a decision about treatment, the requirements of the MCA 2005
must be followed, and if relevant, an application made to the Court of Protection.
Doctors and health professionals should always consider the implications of deviations from accepted practices in light of the greater availability of practice guidelines for court guidance. The documentation should include a clear documentation
of the reason for such a deviation, and it should also be clearly explained to the
patient. Clinicians-in-training should be aware that they are expected to seek advice
and assistance in scenarios where they lack experience [20]. Every practitioner
should also ensure they are fully complaint with their employers’ mandatory
requirements, participate proactively within the appraisal and continuing education
processes. It is important, both at a system and individual level, to maintain good
18 Medicolegal Aspects in Diabetic Foot Disease: How to Keep Patients Safe, What…
231
lines of communication with patients and their carers/families. When an adverse
event occurs, ensure a duty of candour is performed, that apologies are offered, and
that learnings from the investigation are relayed to the involved team and the patient
and their carers/families in an emphatic, timely manner.
Every organisation, doctor and healthcare professional should be encouraged to
familiarise with the role of NHS Resolution and engage with the ‘Getting It Right
the First Time’ (GIRFT) initiative. The GIRFT programme was developed to
improve the treatment and care of patients through a recurring in-depth review of
services, benchmarking, and data-driven evidence presentations to support change
within healthcare organisations. For diabetic foot disease, GIRFT triangulates
around the specialties of vascular surgery, diabetes and orthopaedic surgery. In collaboration with NHS Resolution, GIRFT has produced the Learning from Litigation
Claims: best practice guide for clinicians and managers document [28] which
should be essential reading for healthcare providers and professionals likewise.
When things go wrong, it is important to recognise and acknowledge. Saying sorry
to the patient and family as soon as possible in a sincere way, is the right approach
and as per the Compensation Act 2006 does not itself amount to an admission of
breach of duty or negligence [29]. Such an early intervention may, as part of a wider
coordinated communication initiative allow the patient and/or family to understand
what went wrong without resorting to complaining or taking legal action.
In summary, clinicians and service providers are likely to see an increase in litigation related to diabetic foot care. The recent NHS resolution review has identied a
number of themes which, individually or collectively, can increase the likelihood of
sub-optimal outcomes and expose the system to litigation. When litigation occurs, it
can be a long process with signicant personal stress to individual members involved.
A system wide approach is necessary to improve the patient pathway when a DFU
occurs, and it is essential that individuals are cared for within a MDFT environment.
Furthermore, it is important that doctors and healthcare professionals, involved in
managing diabetic foot disease, continue to demonstrate best practice behaviour, clear
documentation, and reection, even within the constraints imposed on them.
Key Points
Litigation has signicantly increased and most commonly occur after major and
minor amputation.
Common themes of litigation include lack of screening, delays/failure in diagnosis and accessing specialist foot care services, failing to order appropriate investigations and variable quality of the care.
When a patient lacks capacity to consent to treatment the Court of Protection
should be involved early.
Most clinical negligence claims are resolved without formal court proceedings.
A successful negligence claim needs to prove a duty of care was owed to the
claimant by the Trust or Practioner and that there was a breach of that duty of care
which resulted in harm.
It is essential that a Healthcare Practioner are involved early with clinical negligence claims and the multidisciplinary teams discuss these cases to identify learning.
232
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P. Vas and V. Butler-Cole KC
References
1. NHS Resolution report 2022. Diabetes and lower limb complications: a thematic review of
clinical negligence claims. 2022. https://resolution.nhs.uk/2022/06/13/diabetes- and- lower-
limb- complications- a- thematic- review- of- clinical- negligence- claims/. Accessed 24 Jun 2022.
2. Fenn P.Counting the cost of medical negligence: NHS litigation authority will be able to report
on costs and high risk procedures. BMJ. 2002;325:233–4.
3. Ten Anderson A.Years of maternity claims: an analysis of the NHS litigation authority data–
key ndings. Clin risk. 2013;19:24–31.
4. Ring J, Talbot C, Clough T.Clinical negligence in foot and ankle surgery: a 17-year review of
claims to the NHS litigation authority. Bone Joint J. 2014;96:1510–4.
5. Birks Y, Aspinal F, Bloor K.Understanding the drivers of litigation in health services. Report.
England: University of York and the King’s Fund; 2018.
6. National Cardiovascular Intelligence Network. National diabetes foot care report. 2022.
https://ngertips.phe.org.uk/static- reports/diabetes- footcare/national- diabetic- footcare- report.
html Accessed 25/06/2022).
7. Rayman G. Inpatient diabetic foot care: a UK perspective. In: Boulton AJM, Rayman G,
Wukich DK, editors. The foot in diabetes. Hoboken: Wiley; 2020. p.259–64.
8. HOIP.National diabetes foot care audit: fourth annual report. 2019. https://www.hqip.org.uk/
resource/national- diabetes- foot- care- audit- fourth- annual- report/#.YcxK1y- l2Lc. Accessed 16
Oct 2020.
9. Johnston C, Liddle J.The mental capacity act 2005: a new framework for healthcare decision
making. J Med Ethics. 2007;33:94–7.
10. Natovich R, etal. Cognitive dysfunction: part and parcel of the diabetic foot. Diabetes Care.
2016;39:1202–7.
11. Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M.A cohort study of people with diabetes
and their rst foot ulcer: the role of depression on mortality. Diabetes Care. 2007;30:1473–9.
12. Chamberlain RC, et al. Foot ulcer and risk of lower limb amputation or death in people
with diabetes: a National Population-Based Retrospective Cohort Study. Diabetes Care.
2022;45:83–91.
13. Amir L.Managing chronic conditions: economic analysis can help mitigate costs of diabetic
ulcers. Healthcare nanc Manage. 2014;68:90-94, 96.
14. Endean N. The court of protection and health and welfare matters. Nurs Resident Care.
2020;22:1–3.
15. Bekara F, etal. New techniques for wound management: a systematic review of their role in
the management of chronic wounds. Arch Plast Surg. 2018;45:102–10.
16. Hinchliffe M.The role of the ofcial solicitor to the supreme court. J Child L. 1988;1:64.
17. Series L.The place of wishes and feelings in best interests decisions: Wye Valley NHS trust v
Mr B.Mod Law Rev. 2016;79:1101–15.
18. Halpin S. Recent changes in UK medical law: implications for radiologists. Clin Radiol.
2020;75:740–5.
19. Escandon J, Vivas AC, Perez R, Kirsner R, Davis S.A prospective pilot study of ultrasound
therapy effectiveness in refractory venous leg ulcers. Int Wound J. 2012;9:570–8.
20. Bryden D, Storey I.Duty of care and medical negligence. Continuing education in anaesthesia.
Crit Care Pain. 2011;11:124–7.
21. Powers M, Barton A, Jackson B.Clinical negligence. London: Bloomsbury Publishing; 2015.
22. Dorries C. sudden infant death investigation in the UK–the coroner’s perspective. Cambridge:
Cambridge University Press; 2019.
23. National Institute for Health and Clinical Excellence (NICE). The MIST therapy system for
the promotion of wound healing. Medical technologies guidance 5 [MTG5]. 2011. London,
UK: https://www.nice.org.uk/Guidance/MTG5.
24. van Dellen A, Harris A, Merryweather J, Simsek C, Pendlebury G.What the psychiatrist needs
to know about the coroner's court in England and Wales. BJPsych Advances. 2022;28:187–94.
18 Medicolegal Aspects in Diabetic Foot Disease: How to Keep Patients Safe, What…
25. Jeffcoate W, Young B.National Diabetic Foot Audit of England and Wales yields its rst dividends. Diabet Med. 2016;33:1464–5.
26. Li Q, etal. Delays to revascularization for patients with chronic limb-threatening ischaemia.
Br J Surg. 2022;109:717–26.
27. Vas PRJ, etal. The diabetic foot attack: "'Tis too late to retreat!". Int J Low Extrem Wounds.
2018;17:7–13.
28. Chuang LH, etal. Economic evaluation of a randomized controlled trial of ultrasound therapy
for hard-to-heal venous leg ulcers. Br J Surg. 2011;98:1099–106.
29. NHS Resolution Saying Sorry. https://resolution.nhs.uk/wp- content/uploads/2017/07/NHS-
Resolution- Saying- Sorry- Final.pdf. Accessed 25 Jul 2022.
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Index
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A
Achilles tendon lengthening, 128, 177, 181
ACTNOW, 13, 14
Adherence, 179, 180, 186–189, 191, 192,
194–197, 228, 230
Amputation, 2–4, 7, 8, 12, 13, 15, 16, 31, 35,
58, 77, 96, 97, 102, 103, 106, 117,
126–128, 131, 135–146, 152, 176,
185, 192, 197, 201, 202, 205,
209–212, 216, 217, 220, 223
below the ankle, 117–132
level, 7, 9, 12, 19, 20, 103, 117,
118, 137–138
Angioplasty, 87, 92–96, 101, 109, 111, 112
Antibiotic choice, 24
B
Bone scintigraphy, 59
Bypass surgery, 87, 105, 109–112, 114
C
Cardiovascular, 2, 4, 11, 12, 21, 24, 28, 33, 34,
37, 38, 42, 118, 121, 153–154, 185,
186, 188–191, 194, 197, 203,
204, 217
Change management, 216
Charcot foot, 19, 38, 159, 160, 166, 167,
170, 181–182
Charcot foot reconstruction, 165–170
Clinical negligence, 219, 220, 222,
224–227, 231
Complications of foot in diabetes, 8–14, 16
Computed tomography (CT), 58–60, 63,
144, 151
Court of Protection, 222–224, 230, 231
D
Diabetes
complications, 1–5, 7, 9, 10, 33–40, 43, 66,
145, 147, 181, 191
control, 35–39, 42
related foot disease, 8
Diabetic arterial disease, 83
Diabetic foot
attack, 20, 24, 35, 118, 119, 121, 122
disease, 8, 35–39, 42, 181, 185, 186,
190, 191, 202, 220, 222, 228,
229, 231
infection, 20–28, 31, 69, 71,
73–79, 81, 165
risk, 192
ulcers, 2–4, 81, 178, 186, 190, 193,
203, 217
Diabetic ketoacidosis, 21, 25, 31, 36
Diabetic neuropathy, 42, 118, 153
Diagnosis of infection, 59, 69, 81
Diagnosis of osteomyelitis, 24, 56, 58, 74
Drug eluting balloon, 101, 112
Drug eluting stents, 94, 95, 101, 112
E
Endovascular, 62, 83–85, 87–97, 101, 102,
104, 106, 107, 109, 111–114,
137, 145
© The Editor(s) (if applicable) and The Author(s), under exclusive license to
Springer Nature Switzerland AG 2023
C. P. Shearman, P. Chong (eds.), Management of Diabetic Foot Complications,
https://doi.org/10.1007/978-3-031-05832-5
235
236
Index
F
Foot biomechanics, 11, 175
Foot complications, 1–5, 8–14, 16, 31, 33–40,
43, 55–57, 59–61, 63–66,
170, 201–206
Foot deformity, 10, 120, 121, 155, 159, 161,
168, 175–177, 181
Foot ulcer, 2, 3, 7–9, 12, 35, 36, 39, 83, 107,
155, 162, 167, 170, 176, 185–187,
190, 194, 197, 202, 203, 214,
215, 221
H
Health care costs, 3, 4
Hyperglycaemia, 21, 33, 34, 36, 76, 83
Hyperosmolar state, 36
I
Imaging diabetic foot, 55, 58
Inequality, 206, 216
Inammation, 10, 59, 70, 71, 73, 78, 83,
147–153, 167–168, 180
L
Limb salvage, 20, 26, 85, 102, 106, 107,
111–114, 165, 178, 179, 186
Litigation, 219–222, 227–231
Neuropathy, 1, 2, 4, 8, 10–13, 19, 20, 33, 42,
70, 83, 102, 118–120, 130, 132,
148–150, 152, 153, 157, 159, 166,
176, 177, 180, 188, 190
O
Ofoading, 14, 30, 31, 43, 72, 75, 76, 118,
130, 145, 158, 159, 170, 178–180,
182, 187, 190, 221
Osteomyelitis, 22, 24, 30, 55–59, 66, 69–74,
76–78, 118, 129, 132, 147, 153,
157, 162, 163
P
Pathways, 16, 187, 191, 206, 228, 230
Patient ow, 217
Perfusion, 19, 22, 60, 79, 83, 86, 90, 97, 101
Peripheral arterial disease (PAD), 2, 8, 20, 22,
80, 101–103, 121, 124, 190,
210, 212
Peripheral vascular disease, 38, 60, 69, 70
Plantar pressures, 37, 158, 181, 190
Pre-operative optimisation, 204
Prevention, 8, 9, 11, 12, 31, 95, 153, 178, 185,
186, 189, 192, 194, 195,
197, 202–205
Prognosis, 160
M
Magnetic resonance (MR) and computed
tomography (CT) angiography,
61–64, 66, 121, 144
Magnetic resonance imaging (MRI), 24, 56,
58, 59, 62, 66, 73, 105, 121, 151,
152, 156, 162
Metatarsal head excision, 181
Minor amputation, 3, 111, 117–119, 121–124,
128–132, 176, 180, 202, 210,
220, 231
Modiable risk factors, 185, 186, 189, 190
Mortality, 2, 3, 31, 33, 42, 95, 106, 130, 131,
136, 145, 186, 188–194, 201
Motivational interviewing, 195–197
Multidisciplinary team (MDT), 4, 12, 13, 15,
35, 88, 106, 130, 131, 201–206, 231
N
Negotiation, 9, 227
R
Rehabilitation, 85, 136–138, 142, 145,
146, 189–191
S
Safety, 40, 61, 75, 89, 91, 95, 190
Social determinants of health, 216
Stenting, 87, 93, 95, 101, 109, 111, 112
Sub-intimal approach, 92
Surgical correction of foot deformity, 155, 181
Surgical techniques, 124
Surgical treatment of bone infection, 165
Survival, 8, 69, 85, 87, 94, 97, 186, 189, 192,
197, 217
Syme amputations, 129
T
Tenotomy, 159, 181
Tibial artery occlusions, 84
Tissue glycosylation, 176
Index
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237
Tissue loss, 10, 84, 86, 89–91, 101–103, 106,
107, 113, 114, 117–123, 131, 137,
201, 221
Toe amputation, 27, 119, 123, 125–126,
130, 177
Total contact cast, 168, 178
Transmetatarsal amputation, 123, 125,
127–128, 176, 177, 180
U
Ultrasound, 59, 61, 62, 66, 73, 90, 91, 96, 97,
104, 110, 120, 121, 144, 156, 162
W
Weight bearing imaging, 156
X
X-rays, 24, 55, 56, 59, 72, 73
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