The foot in Diabetes – why things go wrong.

Diabetes is common, and a disease on the increase. In the UK the number of people with diabetes increased by 53% between 2006 and 2013. In 2013 there were 2.9 million diabetes patients. By 2025 it is estimated that there will be more than five million people in the UK with diabetes (ref).

The risk of serious foot problems for those with diabetes  is increased. Diabetic neuropathy – damage to nerves leading to lack of protective sensation, and peripheral arterial disease – diseased blood vessels in the legs, can singly or jointly increase the risk of foot ulceration (ref). Diabetic foot ulcers are common – it is estimated that 10% of diabetic patients will have a foot ulcer at some point. Over 80% of diabetic amputations are preceeded by ulcers (ref).

As a podiatry medicolegal expert a large part of my clinical negligence caseload is diabetes-related. Most of the cases I see involve partial toe, foot or leg amputations because the body-part has become non-viable. Almost all begin with a small ulcer on the foot. Almost all were having regular treatment for their feet, from the GP or GP Practice, or more usually, from the local Podiatry Department.

NICE developed specific guidelines for the care of diabetic feet in 2004. These were updated in 2011. The guidelines are quite specific – they cover assessment, examination, risk stratification, and most importantly, they identify clear pathways should a diabetic patient present with an ulcer. These include having a foot protection service (FPS) in place – for the prevention and management of diabetic foot problems, and having a multidisciplinary foot care service (MDFT) in place – to manage those foot problems which cannot be managed by the FPS (ref).

The MDFT should have, amongst others, vascular surgeons, orthopaedic surgeons, and interventional radiology as part of the team.

If a person presents with a limb-threatening or life-threatening diabetic foot problem they should be referred immediately to acute services, and the MDFT should be informed. NICE are quite clear about this – they even list examples of limb-threatening or life-threatening diabetic foot problems.

In every diabetes case I have given evidence in where the clinical negligence allegation has been upheld,  one or more NICE guidelines or recommendations were consistently ignored.

 

 

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