Miss R was admitted to hospital with a history of vomiting; she also had a previous history of diabetes and hypertension. On admission she was diagnosed with uncontrolled diabetes and hypertension, and ketoacidosis was ruled out. She was treated with IV fluids and other medication as her diagnosis warranted. Miss R was noted to have an IV infusion in her right arm after a few days but it is unclear how long this was in place.
Two days later, Miss R visited the Emergency Department (ED), complaining of pain and swelling in her right forearm, which reportedly occurred after she was administered an IV infusion during her previous admission. She was treated with IV fluids, insulin and a Voltaren injection for the pain. She also had an x-ray of the affected arm and was kept for observation.
Miss R was referred to the Internal Medicine Department, where Dr V diagnosed cellulitis of the right forearm and hand. Miss R was prescribed Voltaren for the pain, antibiotics, aspirin, Lipitor, Zestril, sliding scale insulin and vitamin C. She was then transferred to the Female Medical Unit for further management.
A day later, Miss R’s condition was recorded as stable but she continued to complain of pain to the affected arm, which remained swollen. Her previously prescribed insulin dosage increased almost daily due to persistently elevated blood sugars. However, a few days later, Dr V recorded that Miss R was not receiving her correct dose of insulin. Some discrepancies were observed between the dosages of insulin ordered and the amount administered.
Two days later, Miss R was seen by the surgical team. Her right arm was described as oedematous and tender up to the forearm and erythematous. Miss R was unable to grasp with her fingers. She was again diagnosed with cellulitis of the right forearm, and an incision and drainage of the affected arm were performed, with serous fluid aspirated. Fortum and gentamycin were added to Miss R’s previous medication.
The following day there was a slight improvement in the swollen arm but Miss R continued to complain of pain. She was seen by Dr K, a consultant in general surgery. A fasciotomy was carried out after a review of the affected arm revealed unhealthy necrosed tissue, which appeared to be due to diabetic ischaemic necrosis of the right forearm. Radial pulse was not felt and there were no active finger movements. Following the fasciotomy, Miss R’s blood sugar remained elevated.
Miss R was then reviewed by Dr M, orthopaedic consultant, who noted partial necrosis of the right forearm and no sensation or pulsation in the affected arm. The prescribed treatment continued and Miss R was monitored by doctors from the internal medicine and surgery departments.
Miss R’s blood glucose remained uncontrolled. An arterial Doppler examination was performed, followed by an exploration of the brachio-radial artery. There were further surgical interventions carried out on Miss R’s arm over the next month: three debridements and a secondary suturing of the forearm.
The general condition of Miss R’s affected arm continued to deteriorate. She had regular dressing changes and prescribed medication inclusive of insulin and antibiotics continued. Her blood glucose levels continued to fluctuate. The condition of the wound also fluctuated – between a red and healthy appearance to sloughy. Miss R then developed pseudomonas infection to the wound, which was treated with the required antibiotics. The wound healed gradually and glucose levels finally became controlled. She was discharged from surgery and her treatment continued in internal medicine.
Following satisfactory control of Miss R’s blood glucose levels and the healing of the wound, she was discharged from hospital, after which she received physiotherapy as an outpatient.
Miss R lodged a claim against the hospital for various aspects of her treatment. She alleged that her infections and subsequent surgical interventions could have been avoided with more timely administration of her antibiotics. Miss R also claimed that incorrect dosages of insulin worsened her infection, and that there were delays in her admission to internal medicine and the surgical department.
As with the previous case, there was a delay in the claim being served – therefore, the MPS legal team applied to have the claim struck out. This application was successful.
With thanks to Dr Jonathan Bernstein for his assistance with this article.