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Care of persistent leg condition in insulin-dependent diabetic (03HDC02828)
Download Care of persistent leg condition in insulin-dependent diabetic (03HDC02828) (PDF 12Kb)
(03HDC02828, 9 November 2004)
General practitioner ~ Standard
of care ~ Ulcerative condition ~ Unstable diabetic ~ Right
A man's right leg was amputated below the knee as a result of a
persistent leg condition, which had worsened over an eight-month
period. The man's son complained that his father's GP should have
treated his father with more care, given that he was a 76-year-old
with poorly controlled diabetes. The son also felt that concerns
raised by the district nurses caring for his father did not appear
to have been followed up by the GP.
In April 2002, the patient consulted his GP about an inflamed and
painful right ankle, and at the next consultation in July, the
patient complained of rest pain. The rest pain continued and
subsequently an ulcer developed on his right ankle, and oedema,
erythema, crusting and blistering lesions appeared on both legs.
The patient's blood sugar levels over this period also indicated
that his diabetes was difficult to control.
At various times, the patient was seen by district nurses, a
diabetic nurse, a wound care specialist nurse, and a dermatologist.
He was not seen by a vascular surgeon (as he had been in July 2000)
or a diabetes specialist, even though on several occasions such
referrals were suggested to the GP by the attending nurses.
On 9 December, the patient was admitted to hospital with erythema,
tissue ooze, and bullae. When his condition deteriorated he was
transferred to another hospital, and on 31 December his lower right
leg was amputated.
The GP stated: "At all times I was duly cognizant of the fact that
diabetes increased the risk of progression of the condition of his
legs and would reduce the rate of healing. It is for this reason
that we kept [the patient] under close scrutiny during this time.
When it was apparent that vascularity was compromised, the
appropriate referral was made."
The Commissioner's general practice advisor considered that, as
early as July, there were enough important indicators to suggest
that the patient had a serious condition that warranted referral to
a specialist or hospital.
A GP who made submissions on behalf of the patient's GP criticised
the expert opinion, saying that it reflected the advisor's
specialist background and set an unrealistically high standard that
is not reflective of general practice. The vascular surgeon
advising ACC on the medical misadventure charge also said that,
while referral to a vascular specialist would have been appropriate
in August, there was no evidence that the patient's GP had failed
to observe a standard of care and skill in the circumstances.
In the face of this conflicting advice, the Commissioner felt it
unreasonable to find the GP in breach of his duty of reasonable
care and skill under the Code. However, if the expert's advice is
currently regarded as "too gold standard" and exceeds accepted
practice standards for GPs in New Zealand, further education is
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