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Information provided before administration of steroid injection (12HDC00347)

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(12HDC00347, 20 June 2014)

Podiatrist ~ Steroid injection ~ Care ~ Informed consent ~ Administering injection ~ Documentation ~ Rights 4(1), 4(2), 6(1), 7(1)

A woman underwent ankle fusion surgery on her left ankle, which left her with a long-standing scar. She also sustained nerve damage to the left side of her left foot, which had not caused her any trouble. A few years later, the woman developed problems with her right ankle, and subsequently consulted a podiatric surgeon. She was diagnosed with peroneal tendonitis of the right foot. At this consultation, the podiatrist injected the woman's right foot with local anaesthetic and Kenacort, a corticosteroid.

At the next consultation orthotic therapy was initiated. The podiatrist also recorded that there was a discussion about treating the entrapment neuropathy in the woman's left ankle by steroid injection.

The woman returned for a check of her orthotics, and the podiatrist administered a Kenacort injection with local anaesthetic to her left foot. She stated that the podiatrist did not inform her of the risks of tissue breakdown associated with having the Kenacort injection into her left ankle. Within one week of the injection being administered, the old scar line on her left ankle became inflamed, and she had heightened sensitivity and pain. She was also experiencing problems with the orthotics dispensed by the podiatrist.

At her next consultation six weeks later she was reassured by the podiatrist that her left foot looked good, that she should expect pain in her left ankle, and that she did not require antibiotics. He also advised that it was normal to have difficulty wearing the orthotics, and she needed to get used to them.

Nine days later the woman consulted her GP who noted that she had an open wound on the left ankle at the site of the injection, along with a 6mm infected ulcer. Her GP cleaned and dressed the wound, and prescribed a course of flucloxacillin.

Over the next four months, the woman had her wound cleaned and dressed by the nurses at her medical centre. She was referred to a plastic surgeon who advised her that the steroid injection had caused her wound breakdown, and recommended surgical revision as the best treatment option.

The woman underwent debridement and repair surgery to her left ankle, performed by the plastic surgeon. Unfortunately, the surgical wound broke down and she continued to require follow-up care for her left ankle at her medical centre. The woman required new orthotics, which were dispensed to her by another podiatrist. She was also referred for surgery to repair the tendon and ligament in her right foot.

It was held that the podiatrist failed in his duty to provide the woman with information on the risks and complications associated with a corticosteroid injection into her left foot. Accordingly, it was found that the podiatrist breached Right 6(1) by failing to provide the woman with information that a reasonable consumer in her circumstances would expect to receive.

As the woman did not receive sufficient information, she was not in a position to provide informed consent for the corticosteroid injection to her left ankle. Accordingly, the podiatrist breached Right 7(1).

The woman had a history of Type II diabetes and previous wound breakdown. These factors placed her at increased risk of tissue breakdown, and certain assessments should have been carried out and precautions taken in relation to the steroid injection in her left foot. In particular, the podiatrist should have considered the option of an X-ray, and should have performed a lower limb neuropathy and venous return assessment, carried out an early review of her foot, and suggested prophylactic antibiotics following the injection and ensured that antibiotics were prescribed when the woman later complained of increased sensitivity in her foot and tenderness at the injection site. By not carrying out these assessments and taking these precautions, the podiatrist failed to provide services with reasonable care and skill, and breached Right 4(1).

The podiatrist's documentation lacked sufficient detail, and did not provide an adequate clinical picture of the woman's medical history and the treatment he provided to her. His substandard clinical documentation was a breach of professional standards and, accordingly breached Right 4(2). 

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