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Not on sound footing

01 May 2009

Mr B was a 35-year-old bus driver, with a wife and two children. He smoked and was overweight, but found it hard to lose weight due to the sedentary nature of his job. He had noticed that his right foot had become gradually more and more painful over the last month, despite the fact that he had not injured it, until the pain was very severe.

He went to see Dr T, one of the partners in his GP practice, and explained that this severe pain was not being helped by maximum doses of paracetamol and ibuprofen. He also mentioned that his foot kept changing colour from white to blue. Dr T looked at his foot very briefly and diagnosed a “sprain”, despite the lack of trauma in Mr B’s history. He did not check for pulses or feel Mr B’s foot to check sensation or temperature of the skin.

Over the next five weeks, Mr B visited the practice several times and saw three different partners, complaining of worsening pain in his right foot. None of the GPs undertook a new history of events, all assuming that the first doctor had done this adequately. One of the GPs even arranged an x-ray to exclude a stress fracture.

On no occasion was a complete neurovascular examination documented, despite several entries in his notes of a “discolouration of the foot” and “blue skin”. None of the GPs asked him about cardiovascular risk factors, such as smoking.

Six weeks after his first attendance, Mr B could no longer cope with the pain. He asked for an urgent appointment and was fitted in with the GP registrar at the practice.

The registrar started from the beginning and took a full and careful history, eliciting the lack of trauma, the severity of the pain and the discolouration. Mr B felt he had been listened to for the first time. The registrar made a thorough examination of his foot and was unable to feel the posterior tibial or the dorsalis pedis pulses in his right foot.

The foot was numb, cold and blue. She documented this worrying neurovascular examination and sent Mr B urgently to the emergency department.

Subsequent investigation revealed occlusion of the popliteal artery. Mr B required a below-knee amputation for an ischaemic foot. The aetiology of the ischaemia was never determined.

Mr B made a claim against the practice. Expert witnesses agreed that all three GP partners had failed to take a proper history or make a complete examination of Mr B. Their belief was that an earlier diagnosis would have probably resulted in a better outcome and amputation would have been avoided. The claim was settled for a high amount.

Learning points

  • Always ensure that you take a comprehensive history of the patient yourself. Avoiding dependency on previous consultations could prevent recurrent mistakes.
  • It is always important to listen to the patient.1
  • The fact that there was no trauma involved should have alerted those involved to a range of alternative diagnoses. Attention should be paid to potential predisposing factors, eg, smoking and obesity.2 
  • Having an “open mind” when facing any medical dilemma may lead you to a different conclusion from that of your colleagues. 
  • Whilst it is possible that a neurovascular examination was performed in one of the previous visits, it was not documented. Good documentation is good practice, but it is also the basis for a good defence.2

References

  1. GMC Good Medical Practice, relationships with patients, good communication – paragraphs 22-23 
  2. GMC Good Medical Practice, good clinical care – paragraphs 2-3
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