Improving outcomes for patients with diabetes

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More than 4.9 million people in the UK have diabetes. There are roughly 850,000 people currently living with type 2 diabetes who have not yet been diagnosed. Diabetes leads to more than 9,500 leg, toe or foot amputations every year, or 185 a week.

Early diagnosis of diabetes, and optimal management of risk factors that could lead to complications, is essential to improving patient outcomes. This includes prompt identification and management of risk factors that relate to lower limb health.

To mark World Diabetes Day, 14 November 2021, we spoke with Nicole Mottolini, NHS Resolution Safety and Learning Clinical Fellow for patients with diabetes and lower limb complications, about her work and commitment to improving outcomes for patients.

Nicole, please tell us about yourself

I qualified as Podiatrist in Western Australia. Following graduation, I took up a graduate position at one of the major teaching hospitals in Perth and realised how much I enjoyed the area of Podiatry known as ‘Management of the High Risk Foot.’ This area of Podiatry essentially specialises in the management of patients who are at risk of developing problems in their legs or feet that could put them at risk of amputation. These problems typically arise secondary to conditions such as Diabetes or Peripheral Vascular Disease, or in the presence of a lower limb deformity.

I moved to London about eight years ago and started my career in the NHS. I worked as a locum and therefore had the opportunity to work across a number of different trusts and in a variety of clinical settings. This was extremely beneficial for me in understanding how the various functions of the NHS fit together, but it also highlighted how differently they can operate.

Please tell us about your role at NHS Resolution

I was delighted when I saw the Clinical Fellow role in the Safety and Learning team at NHS Resolution. For me, diabetic foot care is not brought to the forefront of healthcare discussions as much as I would like, so the fact that NHS Resolution had chosen it as an area of focus was really inspiring and encouraging to me.

At NHS Resolution I work in the Safety and Learning team where I am undertaking a thematic analysis of closed clinical negligence claims involving patients who have diabetes and a lower limb complication. I am trying to identify the qualitative themes [1]within the claims, to then be able to write the findings up as a report, and share any learning back into the wider healthcare setting.

Please could you describe the thematic analysis?

The thematic analysis looks at closed claims that involve patients who have diabetes and a lower limb complication. The majority of patients involved in the claims follow a clinical scenario where they have a non-healing diabetic foot ulcer, and then progress to undergoing a major lower limb amputation.

In undertaking this thematic analysis I have tried to consider the full patient journey, rather than just specifically looking at the incident in question. By understanding as much as we can about the context in which the incident occurred, we can hopefully help to gain a better understanding of the systemic factors that can contribute to poor patient outcomes. For example we have looked at the movement of patients between services and the communication between different teams.

How does the thematic review you are involved in at NHS Resolution aim to improve patient outcomes?

This thematic analysis aims to raise awareness, promote discussion and encourage further research on the topic of diabetes and lower limb complications. We hope to highlight why lower limb complications can represent very serious problems, and that this is a condition that should be prioritised. We hope to promote the key message: that a significant portion of lower limb amputations are preventable, but in order to prevent them we need to ensure that we work together to improve the current care pathways for this group of patients.

The overall aim for this project is that it will help lead to a reduction in lower limb amputations and an improvement in patient outcomes. This is not a unique aim of course – there are plenty of teams across the NHS working towards the same goal and there are certainly examples of success in this area already. However, we are hoping to help create more national consistency in the care that is delivered to patients with diabetes-related lower limb problems. We hope the learning drawn from this claims review will be applicable, and relevant to all services involved across the entire patient pathway.

The report also seeks to highlight the importance of being able to transfer learning into clinical practice. We hope to encourage the identification of any barriers that currently exist and translate current research and evidenced-based guidance into widespread clinical improvements and consistent national standards.

We hope to develop any recommendations in partnership with other clinical teams, networks and governing bodies that share our aims. We hope to be able to work with these teams to drive improvements across the healthcare system that will improve outcomes for patient but also hopefully improve staff experience, and reduce costs to the NHS.

Where do you think working for NHS Resolution brings the most value for you?

The purpose of the thematic review aligns with one of the main aims of NHS Resolution – sharing learning for improvement from when things go wrong in healthcare settings.

When things go wrong in healthcare, it is vital that we learn in order to improve and prevent the same thing from happening again. For me, it’s really important to be able to honestly say to patients – when things go wrong, we take it incredibly seriously and try to stop it happening to another patient. Working for an organisation that resonates with my values on patient safety is incredibly valuable to me and NHS Resolution has championed Saying Sorry for a long time.

This opportunity, working away from day-to-day clinical practice, has provided me with a unique perspective on the care that we deliver for patients with diabetes and lower limb complications. I feel very fortunate to have been able to step back and gain a broader understanding of the wider NHS systems and processes that are behind the care that we deliver. I have found this aspect of the role incredibly insightful and I look forward to being able to take this knowledge back into clinical practice.


Nicole’s thematic analysis is available to read – Diabetes and lower limb complications: A thematic review of clinical negligence claims.

For more information about Safety and Learning at NHS Resolution, visit our Safety and Learning homepage.