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Missed critical limb ischaemia

01 May 2015

Mr S was a 60-year-old lorry driver. He was overweight and smoked, and couldn’t walk far because he suffered with pain in his calves. During a long drive he became aware of pain in his right calf and foot. This became so severe that he attended the out-of-hours service that evening. The GP measured both calves and found them to be the same. A history of forefoot pain but no calf tenderness was noted and a DVT was excluded. He told Mr S he likely had a problem with his circulation. Mr S was prescribed aspirin and advised to consult with his own GP for further follow-up.

Mr S struggled to sleep for the next two nights because he had a burning sensation in his right foot and lower leg, which felt cold and numb. He had to get up and walk around to relieve the pain. He made an appointment with his own GP, Dr A, the next day. Dr A noted the history of numbness and rest pain. He documented that his right foot was pale and felt cold. He requested a non-urgent Doppler assessment because he could not detect any pulses in his right foot and prescribed quinine sulphate.

Mr S’s Doppler scan was arranged for the following week but he rang his GP surgery three days later because the pain in his foot and lower leg was becoming more severe. He had to hang his foot over the edge of the bed to get relief from it. Dr A advised him to go straight to the Emergency Department (ED).

The ED doctor sent him home despite documenting limb pain at rest and a cool, pale right foot with weak pulses. The diagnosis of arterial insufficiency rather than acute ischaemia was made. Mr S was advised to stop smoking and to attend his Doppler assessment in four days’ time.

Mr S was really worried about his leg despite being reassured in the ED. He rang his GP explaining that his leg was still very painful and was becoming swollen. Dr A reassured him because he had been discharged home from the ED and advised him to come for his Doppler scan the following day. When he attended the operator was unable to get a result due to swelling and pain but noted that his foot pulses were difficult to detect. Mr S was given an appointment with Dr A the next day to discuss the results.

Dr A discussed the Doppler results and documented that his right foot was cold. He made the diagnosis of “worsening peripheral vascular disease” and arranged for Mr S to attend the surgical assessment unit the following day.

Mr S was admitted urgently from the surgical assessment unit with a diagnosis of an acutely ischaemic right leg. On femoral angiography, he was found to have thrombus in the distal superficial femoral artery. He had a right femoral embolectomy, which was unsuccessful and converted to a right femoral popliteal bypass. Unfortunately his leg was still not viable following this procedure and he went on to have an above knee amputation. Mr S suffered with phantom limb pain and despite undergoing rehabilitation he remained severely limited in his daily activities.

He was devastated and made a claim of negligence against his GP. It was alleged that Dr A had not appropriately acted upon his symptoms of rest pain or made the correct diagnosis of critical limb ischaemia. It was claimed that Dr A had failed to refer him for urgent surgical review and that he had wrongly asked him to wait for a week for a Doppler scan.

Expert advice

MPS sought the advice of an expert GP. She felt that Dr A had performed below the acceptable standard of GP care. She considered that there was sufficient evidence of critical ischaemia in the description of rest pain at night coupled with an alteration in colour and temperature of the foot. She said that this required urgent same-day surgical assessment.
  
She felt that there was no clinical indication for quinine sulphate and the decision to request a Doppler scan, which was clearly not performed with any degree of urgency, was insufficient in the light of the history and clinical findings.

  
The opinion of a professor in vascular surgery was also gained. He considered that Mr S’s foot was obviously ischaemic when he presented to his GP. He thought that an amputation may well have been avoided if Mr S had been admitted earlier. The case was settled for a high amount against both the hospital and the GP.

Learning points

  • NICE has published useful guidelines on the diagnosis and management of lower limb ischaemia.
  • Critical limb ischaemia is characterised by any of: rest pain, arterial ulceration or gangrene. It has a high risk of amputation. If a patient has rest pain they need same-day surgical assessment.
  • You should not be completely reassured by another doctor’s assessment. In this case the GP had been reassured by the diagnosis in the ED, which was incorrect. Doctors should use their own clinical acumen.
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