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Malpractice or clinical risk? Iatrogenic injury in PVD

Discussion in 'General Issues and Discussion Forum' started by tonywatson12, Jan 23, 2014.

  1. tonywatson12

    tonywatson12 Active Member

    Members do not see these Ads. Sign Up.
    patient attends community podiatry for routine nail care and plantar cal reduction.
    medical history shows pvd.
    noted as at risk foot due to this.
    during treatment pod flap hems patient.
    after appropriate dressing patient is asked to attend in 1 week to check wound.

    at this check the area has failed to show healing.

    outcome patient fails to heal and sometime later has a bka.
    the solicitors letter has the line " the patient has never had any problems before this visit" and the claim is for malpractice.

    should the patient have consented to routine podiatry with a consent type form that outlines all risks of podiatry treatment?

    is this a acceptable clinic risk?

    what's your views?
  2. Re: malpractice or clinical risk?


    Could you please explain what a "flap hem" is - the terminology conjures up all sorts of unpleasant thoughts most of which would undoubtedly provoke a malpractice claim?

    I would need to know more. What agent was used to cauterise the wound? What dressing and what off loading was applied? What advice was the patient given? Why the delay in reviewing the wound? What happened subsequently? What protocols were followed including referral guidelines to the specialist wound care team and vascular surgeon?

    Accidents happen. It's called adverse outcomes and its an acceptable clinical risk. It's what you do subsequently that determines liability.
  3. tonywatson12

    tonywatson12 Active Member

    Re: malpractice or clinical risk?

    hi mark
    skin flap made by scalpel during debridement say .5-1. cm shallow.
    scenario is around some complaints i have seen over the years but follows how some have progressed.
    in the case of dressing it would have been sterile gauze and tape say hapla and the only off loading would be what was needed for soft tissue lesions but would be limited due skin fragility risks in the ischemic foot.
    may have used kaltostat but as reduced microvascular supply bleeding limited.

    the follow up dressing was based on a nhs type community clinic attended one a week.
    patient would have been advised to call if any problems.
    standard advice at this point would have been to keep dressing dry and clean.

    the pathway following the second visit usually would be dressing with possible felt off loading and referral to the high risk team.

    the question is around the claim made to the pod that made the skin flap and that prior to this the patient had never had a foot problem and perceived the cause of her/his leg loss was this incident. the patient had no complaints at the care following this.

    So is debridement in this case for painful cal and the injury an excepted clinical risk
    and if so should we get written consent for routine debridement in the high risk patient?
  4. Re: malpractice or clinical risk?

    Is this just a hypothesis or is it an actual case? Actually, better you don't answer that. Let's assume its hypothetical.

    So there is this podiatrist - call him Mr SWIM and he has a bad day and inadvertently trumps whilst seeing this high risk vascular compromised patient and slices the No 10 through a significant rump of plantar skin. What would we expect him to do? Certainly stop the bleed. That helps. Nothing worse than blood skooshing over the side of their shoes when exiting your surgery - aside from unnerving the next patient(s), there's always the risk from slipping - and you know the size of the form you have to fill in if you work for the NHS and this happens. Indeed, it would be better if the patient died at this point, rather than slip and fracture a hip, say.

    So SWIM appiles direct pressure and maybe a strand or two of sorbsan and a sterile dressing and tape and sends her away, fingers crossed. No way SWIM would have used FeCl3 or AgNo3 or even viper's venom due to her desperate circulation - unless she was a traffic warden or a Tory or a relative of Tony Blair - in which case a small blow-torch might have been considered.

    And SWIM would have thought about the off-loading issue - as it's really quite important. Best way is just to keep off her feet altogether and he would have counselled that - after apologising profusely for the trump and slice incident. And he might have arranged someone to go round to see her - maybe a relative or a carer. And of course he would have called her later that evening to see how she was.

    Being that sort of person, SWIM would have said "fcuk the NHS protocols" I would like to see this lady back in two days so he could check the wound had closed and see if it was healing uneventfully. If it wasn't, then he would arrange some Flucox as a prophylaxis and see if he could get her into a non-weightbearing air cast boot - just to be absolutely sure it was not going to be subject to any pressure.

    He might see he back again in a couple of days - just to check her progress - and no doubt at this point things would be moving on nicely, but if it wasn't and thing were beginning to seem ominous and SWIm wasn't sure what he could do next - then he would sit down and get on the telephone and speak to her GP and say "look pal, I'm no happy with this" and not hang up until the GP has promised on his daughter's life that this poor lady would be admitted for obs.

    That's what I might expect to see happening. Start from the point where you imagine you were on the receiving end of the trump and slice and your circulation was knackered. What would you expect to be done and when?

    Its fairly easy after that.
  5. Tuckersm

    Tuckersm Well-Known Member

    Re: malpractice or clinical risk?

    We use to provide a general brochure to all new patients explaining that we used sharp instruments and that injuries could occur etc.

    Comes down to an informed consent issue, not really malpractice, but a clinical incident, that the patient may well be entitled to compensation for. There is always a need for the patient to also take some responsibility, and expert advise may well indicate that the BKA would have happened anyway.
  6. Ros Kidd

    Ros Kidd Active Member

    Re: malpractice or clinical risk?

    Pardon, did I read a cut 0.5 to 1cm as a flap! Bet that was more painful than the callus in the first place. Sure patients have to take some responsibility as part of a negotiated treatment plan, but if they consented to callus debridement and are aware of the risks involved surely they have a right to expect that the pod can use a scalpel with reasonable competence. I think Mr SWIM might be SUNK.
  7. W J Liggins

    W J Liggins Well-Known Member

    Re: malpractice or clinical risk?

    Absolutely. An incision of that depth is an incision, not a 'flap' and is bound to cause problems on a weight bearing foot. Should have been sutured, and given the PVS, broad spectrum antibiosis prescribed.

    Bill Liggins
  8. tonywatson12

    tonywatson12 Active Member

    Re: malpractice or clinical risk?

    hi the pathway you describe seems a little drastic following a small cut and a primary sterile dressing would normally be the correct treatment and will 9 out of 10 times be all thats needed.

    when ischemic lesions fail to respond vascular assessment is the most vital thing needed along with pain control.
    ? antibiotics with no infection
    do you think sutures would be wise in the plantar of an ischemic patient with fragile skin and the use of air cast in a vascular compromised patient may put more compression on the compromised vessels?

    we as pods cut/hem patients by mistake a number of times no matter how much skill or care (even when not farting!!) i think the leaflet idea at 1st contact is a good one
  9. shready

    shready Welcome New Poster

    Re: malpractice or clinical risk?

    Really! I fail to understand why you think this is the norm, is the leaflet your get out clause..I don't think so.
  10. tonywatson12

    tonywatson12 Active Member

    Re: malpractice or clinical risk?

    yes really

    get out clause for malpractice or clinical risk!
    that is the question ,if patient information and informed consent aided by fully understanding the risk of treatment is made safer with a leaflet then yep i will use it as my get out clause.

    never cut anyone by accident?
  11. blinda

    blinda MVP

    Re: malpractice or clinical risk?

    Sure, but then i dressed, offloaded and checked the site within the recommended 48 hrs for wound closure and infection, etc. Particularly in high risk pts.

    (I hope) This was a great hypothetical scenario for learning outcomes.
  12. Ros Kidd

    Ros Kidd Active Member

    Re: Malpractice or clinical risk? Iatrogenic inury in PVD

    A leaflet is an aid to the overall treatment plan, its not a get out clause for poor care. That is not a minor cut described previously, it's a clinical "insult" to a limb threatened patient. A minor capillary heam' may occur, but should not be expected. The after care in this case is very poor. Certainly if I was the expert witness in court reviewing this case, leaflet or not, I would have to say that this is malpractice. This is not the level of care that a patient should reasonably expect from a podiatrist who feels competent to treat an "at risk" patient. But as Mark says we'll assume its hypothetical.
  13. Craig Payne

    Craig Payne Moderator

    Re: Malpractice or clinical risk? Iatrogenic inury in PVD

    Slightly off topic, but this thread reminds me of a lecture I endured from a vascular surgeon >20 yrs ago in which he listed 5 or 6 causes of amputation in those with critical limb ischaemia - one of those causes was "Podiatry"! ... I had to admit to myself begrudgingly that he was probably right. Several others have related similar stories to me.
  14. tonywatson12

    tonywatson12 Active Member

    would you then say that the clinical risk for cal debridement in this case could result in loss of limb? if the podiatrist makes a mistake with a sharp scalpel.

    or is the mistake in this case malpractice.
    what did the pod do wrong?
    he dressed the area booked a follow up advised to call if any problems, what do you think?

    the outcome will probably be the same from the "accident" bka?
  15. Craig Payne

    Craig Payne Moderator

    These sorts of things happen and having a bad outcome does not automatically mean malpractice ... I guess the real issue is if the quality of the care afterwards (wound dressing regime; advice on what to do; return period for checks; need for vascular consult; etc) was adequate or not.

    I guess the "legal arguments" would be around if "call if any problems" was strong enough advice; if the return period should have been sooner or not; if a vascular consult referral should have been made earlier etc
  16. rosherville

    rosherville Active Member

    PVD or not, is a patient entitled to a degree of skill sufficient to expect that a breach in the skin will not occur by accident ? If the answer is yes, then they have a case for damages.

    If you cause an accident whilst driving, your insurance pays up !

    Any subsequent first aid, however appropriate, will not diminish the liability.
  17. Deka08

    Deka08 Active Member

    We have a high risk procedure consent form. Debridement, TCC, surgery, cam walkers.......Etc, run through a checklist of what's involved and get it signed off. I have heard (from drunken lawyers on my rugby team) that these forms aren't worth the paper they are written on and a good lawyer will still have you. But these go through all the department channels to get approval.
    Best defence = documentation, regardless.
  18. Lab Guy

    Lab Guy Well-Known Member

    Unless your performing an amputation, do not use a scalpel in an ischemic foot. Refer to vascular.

  19. Ros Kidd

    Ros Kidd Active Member

    One must always consider the possibility of doing nothing. I have a suspicion (hypothetically of course) that the pain the patient c/o was due to ischeamia and that's how Mr SWIM got into so much poo because there was no real callus to debride and the tissue was not well perfused. So with this level of PVD referral to the vascular people would have been appropriate with debridement, if required, performed in the controlled environment of a HRFC. So technically that's not doing nothing that's being wise with the best interests of the patient being pivotal. Having said all that, if that is the level of after care for any patient with or without PVD who receives a severe wound like that during treatment the hypothetical protocol needs revisiting with the greatest hypothetical speed.
  20. tonywatson12

    tonywatson12 Active Member

    risks and benefits is that not how most care treatments are worked out ?
    i agree with the do nothing and no scalpel work thinking as the avoiding risk thinking but painful cal is painful cal and the patient may expect some benefit.

    i have also seen the same scenario in vascular compromised patients with O/C and problem nails but in this case doing nothing is usually not an option.

    yes vascular consultant assessment is paramount but not all PVD PAD patients have stents/bi-pass grafts so the patients are still going to end up in your chair for treatment.

    call if any problems i agree is a general statement but what other advice could you give as it covers every thing.

    Dressings i feel were appropriate for the lesion and timescale may seem long but is in my experience quite normal as the patient would have contact numbers ect.
    at 48 hours what would you expect to see in a small wound in a pad patient? could you make the call that it was not healing at this point? yes bleeding may occur but patient would have seen this and called.

    I wonder how the our US pods would manage this due to higher litigation?
  21. Ros Kidd

    Ros Kidd Active Member

    The podiatrist is frequently the health care professional that makes the call to get more invasive care for patients from vascular teams when the patients foot pathology deteriorates. Putting a whacking great flap cut in a high pressure area of the foot requires the patient to have something more than gauze and a 7/7 return. This hypothetical patient is in your care, is the blood supply good enough to use oral antibiotics? will the skin tear with tape? can the patient see what happens on the foot? Almost certainly some degree of tissue necrosis will occur with the flap as the less than adequate blood supply was cut to that tissue. 2/7 is not overkill, neither is a modern dressing or rapid referral on in attempt to save a limb.
    Now its getting late and I'm going to vaso dilate with some Bannrock.....hypothetically anyway.
  22. tonywatson12

    tonywatson12 Active Member

    why antibiotics with no infection?
    dressings depend on type of would and stage in would healing and i still say gause is sufficient for a clean superficial wound were limited bleeding is noted.

    It is interesting that we think the ref to vascular will resolve the problem yes it is the correct pathway but lets say in this case the vascular team had seen this lady and the plan is conservative (not blair type) care as the team felt she was to high risk for any form of intervention.

    lets say (as was in this case) the patients full vascular history is known by the pod and that along with the rest of the case load he sees is high risk.

    she has podiatry needs that include the painful callosities and attends (as she did) each 4 to 6 weeks for podiatry in the NHS.
    she has protective orthosis and footwear is good.
    she has been having routine pod treatment for many years with no problems.

    the outcome for this was at the 1st dressing the small cut in the plantar cal was still open and sore the area had no evidence of infection ( difficult to tell in the ischemic foot)

    the pod then dressed using foam after swabbing the area as much as pain would allow.
    as the insole offered good protection no padding was needed.
    doppler showed monophasic faint sounds which had not changed from the last one.

    urgent ref to high risk team made but outcome was inevitable
    patient bit ****** but legal case was well defended by trust .
    pod shaken but not stirred was more nervous with patient and lost confidence.

    this is why not as a "get out" but as a form of patients understanding that podiatry treatments carry risks the leaflet/consent seems a good idea for high risk patients
    oh, I am not the pod but was in the high risk team the patient came to
  23. Ros Kidd

    Ros Kidd Active Member

    I'm a bit confused ( not last nights Bannrock), did the patient loose her leg, did the court find that the pod had treated the patient with all reasonable care?
  24. tonywatson12

    tonywatson12 Active Member

    the vascular surgical team removed the leg following bi pass graft attempt some time later.
    the case was defended by the trust but the final out come for legal matters I don't know if the trust won or settled I would hope the case was defended and won.

    as always in this kind of thing there are no winners as the pod suffered the stress of the claim and the knock in his confidence.
    the patient lost a leg.

    we must take care to inform the patient of the risks and as the comments suggest take care with treatment planning.
    It seems podiatry carries serious risks even at the minor routine debridement level and we should always be aware of this.
    work safe and inform the patient of all risks seems to be the best we can do
    thanks for all the comments
  25. tonywatson12

    tonywatson12 Active Member

    what's bannrock sounds good!:dizzy:
  26. Ros Kidd

    Ros Kidd Active Member

    Happy Australia Day! Bannrock Station is a pleasant drop best drunk on a pleasant summers evening in the Barossa Valley. It comes either bottled or in 2 Litre casks but it is the same quality in both unlike some wine in cardboard. Usually cost around $10 a bottle. Since we moved to the Barossa Valley, which is a wine growing region, we have done our level best to help the local economy!
  27. tonywatson12

    tonywatson12 Active Member

    the rain is running off the window and its cold here in the uk (as usual)!
    think I will stick to a malt for its warming effect!!
    lots of pods I know have been heading to aus maybe I should join them?
    all the best
  28. W J Liggins

    W J Liggins Well-Known Member

    Per posts 7 & 8. This was not a 'small cut', it was a plantar incision 5 to 10mm deep and 'flapped' at that. The fact that the wound was still open at 1st dressing (I think you stated 14 days) indicates that it should have been sutured and offloaded. Yes, because of the PVS the patient should have been prescribed prophylactic broad spectrum antibiosis stat. Having said that, it is clear that these procedures would not normally be carried out in the chiropody surgery and would, as suggested by other respondents, be properly dealt with by the vascular team.

    Bill Liggins
  29. Re: malpractice or clinical risk?

    Hello Tony - sorry I haven't replied sooner as I was indisposed. I know there is a great fashion for "pathways" these days and whilst generally they are a good idea, it should be remembered that everyone is quite unique and what might be indicated for one may not for another. In this hypothetical case, the question I would ask you (or Mr SWIM) is; with the benefit of hindsight, would you do anything different? If the answer is "yes" - then there is a good probability that a claim for clinical negligence would succeed. The point of having clinical experts treating high risk patients is that they should have the foresight to anticipate correctly a whole range of adverse clinical outcomes and complications. Managing this case in the way you have described is inviting disaster. Even in a routine NHS chiropody clinic - closure with steri-strips and sterile gauze and cotton wool overlay in a surgical sandal with a 24 hour review - should not be beyond even the most inexperienced clinician. All the advice given by others on this thread is excellent and I hope you don't think it is drastic. Losing a limb through negligent treatment certainly is.

    Best wishes
  30. blinda

    blinda MVP

    Signs and symptoms of cellulitis, even in a pt with PVD, are often manifest in the first 24 hours, following breach of the skin. IMO, a seven day return following induced trauma to a high risk pt is not appropriate.

    You say the the small cut in the plantar cal was still open and sore the area seven days post op...would you not agree that a painful, unhealed cut strongly indicates infection? What were the results of the swab?
  31. tonywatson12

    tonywatson12 Active Member

    the wound size/diameter was .5-1cm with depth been shallow.
    Infection was not identified at the swab in 7 days
    wound made by sterile scalpel and dressed with sterile gauze type dressing so clean wound if you like.
    I can understand the thinking for antibiotics but still fail to see how they were indicated in this case with no clinical infection noted and appropriate dressing.

    off loading in a wound shoe (do you mean a darco rocker shoe) as the patient had fitted protective insole in shoes that offered more advanced protection then a standard dressing shoe.

    Are we just throwing things at this that are not needed.
    the problem is one of (if you like luck) having made the small shallow cut while debriding pathological cal in an ischemic patient the pod done all he could but the small cut failed to heal due to ischemia and the disease process as out comes in ischemic ulcers/wounds tend to be poor the small wound progressed into a very painful necrotic ulcer (iv antibiotics needed when necrosis tissue developed infection. pain required morphine and after a failed attempt at artificial bypass graft the option is limited and amputation was the best outcome.

    I can understand the patient's pain and anger and need to blame some one for this.
    And again i can see her point that she had had vascular problems for years and had had the cal debrided a number of times in the past with no problems.

    i think this is a risk we all take when treating ischemic patients even for routine care and agree completely with all your thinking on follow up dressings etc but in this case i feel the podiatrist done all that he could and the outcome was pure luck of the draw

    should the pod have debrided the painful cal ? like you guys said sometimes doing nothing is the best treatment in this patient and i agree but the patient requested the painful cal reduced.

    perhaps a consent form would have helped the patient understand the risk.

    I learned a lot from this case and a lot from all your comments and love the idea o a leaflet outlying the risk of podiatry treatment.

    i also remember the vascular team commenting on how many amputations they have via pods

    thanks for the replies good to debate:good:
  32. W J Liggins

    W J Liggins Well-Known Member


    This thread illustrates the necessity of seeing a copy of the full notes. In an earlier posting you stated:

    "skin flap made by scalpel during debridement say .5-1. cm shallow." Thus indicating the depth of the wound. You now clarify by stating:

    "the wound size/diameter was .5-1cm with depth been shallow." This is inexact but it does at least indicate the wound diameter rather than the depth. Hopefully, this was the case in the notes, since a shallow wound would be more defensible than a deep wound. Even so, the pt. should have been non weight bearing, as mentioned by others, and given the fragility of the patient's PVD - and one may reasonably assume general state of health (although you do not tell us), prophylactic antibiosis would have been advisable. If not, why not? The prosecuting barrister will ask.

    Bill Liggins
  33. rosherville

    rosherville Active Member

    ...would you not agree that a painful, unhealed cut strongly indicates infection ?

    Not necessarily in a patient with PVD, but certainly prophylactic antibiotics are indicated.

    I won`t say more as I think I may have dealt with this !
  34. tonywatson12

    tonywatson12 Active Member

    the topic is up for comment and i am not writing clinical notes!
    look if you did not understand wound size at .5 - 1cm shallow i apologise but we are talking about routine debridement not surgery.

    say for example you PX flucloxacillin at 500 mg and put her in some form of off loading better then the FFO she had (and by magic)! this caused vasodilation and prevented the development of necrosis and painful ischemic ulceration you would be right.

    but say it made no difference to the outcome except the development of gastrointestinal problems and sickness then i don't see the point

    the point is this accident occurred and the outcome was depending on the ability for the patient to heal and this depended on vascular supply

    would you have put an antimicrobial on after the "cut" ?
    thanks for your comments
  35. tonywatson12

    tonywatson12 Active Member

    hi bill just a question how would you record a small cut during routine debridement?
  36. blinda

    blinda MVP

    Yep, what he said. The presentation of this case, which may or may not be hypothetical, is too sketchy to comment further on.

    Whilst it may be true that not all non-healing wounds in an ischaemic foot are infected, best practice would dictate prophylactic ABs in view of the high risk of subsequent infection and further complications in patients with PVD.
  37. tonywatson12

    tonywatson12 Active Member

    probably wise you dont comment any more:deadhorse:
  38. blinda

    blinda MVP


    No need to become personal.

    You have received excellent advice from my learned colleagues. Why raise this ambiguous `hypothetical` scenario on a professional forum, if you don`t wish to hear professional opinions?

    Kind regards,
  39. tonywatson12

    tonywatson12 Active Member

    patient with pvd has painful cal

    pod has full medical notes

    pod is aware of vascular problems
    pod asked to treat painful cal

    pod cuts patient (small cut shallow)

    pod applies sterile dressing gauze

    patient has protective foot wear and TCJ

    pod books patient at 1/52 to check small cut

    at 1/52 wound still open and sore

    pod swabs would ref to high risk team

    patient fails to heal developing painful ischemic ulceration

    despite all therapies available on planet earth results in amputation


    vote now!!!!
  40. W J Liggins

    W J Liggins Well-Known Member

    Frankly, that is rather silly. I have dealt with quite a large volume of legal cases (not as many as some of the posters here), and these cases are NEVER (emphasis) a matter of voting. A court of law is there to determine a case based on the full evidence available and will use causation as the criteria for the decision not the sketchy summary which you have laid out.

    I'm sorry if you have not got the reaction that you wanted but you asked for advice and have received it from some very experienced practitioners. Please try not to be rude because if ever you do end up in a court of law you will find that it will act to your extreme detriment. Barristers will probe such weakness.

    Bill Liggins

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