Diabetes and lower limb complications: A thematic review of clinical negligence claims

Date published:

Standardised care and better education could prevent diabetic patients from undergoing amputations, preserve wellbeing and save the NHS money, an NHS Resolution report has found.

The report identifies themes in compensation claims involving patients with progressive diabetes-related lower-limb complications that in the worst cases can lead to amputation. Up to 85% of amputations are avoidable. Both amputations and other patient harm can be reduced with appropriate, timely care.

Since 2013/14 there has been a steady growth in the volume and value of clinical negligence claims in diabetic patients with lower limb complications in England. Globally, both the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades.

It is important to recognise that in the majority of cases a good standard of care is provided to patients with diabetes by the NHS in England.

This is a detailed report including 92 claims and of these, 55 patients underwent a major lower limb amputation. Only claims that had been settled since 2018/19 and with an incident date after 2012/13 were included in the report.

The report identifies several key time points during the patient journey where intervention could improve care quality. This includes ensuring standardised, evidence-based assessment techniques are used to diagnose the patient promptly.

Once a patient has been diagnosed, the report highlights the importance of rapid access to a multi-disciplinary foot team (MDfT). This team would provide oversight and management of the entire patient care pathway to ensure consistency, appropriate timely decision making and follow up. Follow up includes education to empower patients to self-manage and commence safe foot and lower limb care habits.

One of the issues highlighted in the report is that patients often do not know that their condition is getting worse because they don’t feel pain, due to a condition called neuropathy, resulting from nerve damage. This means patients often delay seeking help.

The report also found that diabetic foot disease is a condition that is not always well recognised or taken seriously. It highlights the need for a national focus on this issue, to ensure that the both clinicians and patients are better equipped with the right information to take preventative action early.

As well as impacting the patient’s physical and mental wellbeing, delays in diagnosis and treatment have financial costs. Managing the diabetic foot, coupled with the cost of associated lower limb amputations, costs the NHS up to £1 billion annually.

Co-developed with experts across the healthcare system, the report includes seven recommendations to improve the care of diabetic patients with lower limb complications. Work with stakeholders will continue over the coming months to help implement the suggested recommendations.

One of NHS Resolution’s aims is to learn from incidents of harm and share learning as widely as possible. We hope this report will contribute to reducing the number of patients that suffer with severe diabetic lower limb complications. In most cases, the care of diabetic patients with lower limb complications is good, reflecting the commitment of groups of footcare clinicians and networks that work tirelessly to keep standards of care high. Time is tissue’ when it comes to diabetic foot disease. At every stage of the patient journey, acting with urgency is imperative. We hope the recommendations will help to identify and remove some of the barriers that potentially exist in implementing evidence-based and standardised care.

Helen Vernon, Chief Executive, NHS Resolution

Major amputation is one of the most destructive complications of diabetes and regrettably the number of major lower limb amputations in diabetes continues to rise. This report should be compulsory reading for those who are involved with care of patients with diabetes including healthcare professionals, commissioners and policy makers. There must be learning from the diabetes-related lower limb amputations analysed in this report and a thorough appreciation of why they occurred. The report makes recommendations to improve patient care and proposes certain standards which should be put into practice and regularly audited. As a result of this learning it is hoped that the preventable loss of limbs due to diabetes can be reduced.

Michael Edmonds, Professor of Diabetic Foot Medicine, Consultant Diabetologist, King’s College Hospital, who contributed to the report as part of the Clinical Advisory Group


Notes for editors:

  • Diabetes is a lifelong condition that causes a person’s blood sugar level to become too high. High blood sugar levels cause nerve damage which can affect the feeling in feet and damage the circulation, making it slower for sores and cuts to heal.
  • About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.5 million deaths are directly attributed to diabetes each year (WHO).
  • Annually, NHS Resolution is notified of 11,000 clinical negligence claims. Diabetic foot disease, and more specifically a diabetic foot ulcer (DFU), typically precedes a lower limb amputation, with up to 85% of patients who undergo an amputation having a DFU.
  • There are some limitations to the conclusions as the data is drawn from NHS Resolution’s CMS which is not designed as a tool to extract learning. Also, there is great variety in the way diabetic lower limb pathology is described and recorded, which can make it difficult for claims handlers to register these claims in a consistent manner. Irrespective of this, the claims identified were found to have common, resounding themes and we are confident that the learning we can take from these claims is reflective of the majority of claims, and relevant to wider clinical practice.
  • The seven recommendations in the report are summarised below:
  1. Review the level and content of diabetic footcare education
  2. Clear footcare pathway along the entire patient journey
  3. Evidenced based offloading – pressure relief should be mainstream
  4. Review of how diabetes footcare service are commissioned
  5. National public health campaign to raise awareness of diabetic foot disease
  6. Urgent review of current workforce levels
  7. Mandated participation in the National Diabetic Footcare Audit (NDFA) and local service audits