CHAPTER ONE – AMPUTATION CLAIMS: INSTANCES WHICH CAN CAUSE AMPUTATIONS
Potential claims which can give rise to amputations
There are a number of potential claims that can give rise to amputations, both from a personal injury and clinical negligence perspective. Establishing liability in personal injury claims can be more straightforward; claims most commonly arise from a road traffic accident or accidents at work. However, in clinical negligence cases establishing a causal link between negligent treatment and amputation injury can be complex.
Vascular surgery
A significant proportion of amputations in the UK are caused by nerve damage, circulatory problems, vascular conditions or delay in diagnosis of an infection. There is an unusually large number of clinical negligence claims arising from vascular surgery.
In 2021, an observational study[1] was undertaken into the trends of clinical negligence claims in vascular surgery within the United Kingdom. The study found 1,189 vascular surgery claims over the 13 years, showing a consistent upward trajectory that is expected to continue.
Treatment delays were the leading cause of clinical negligence claims in vascular surgery, while lower‑limb amputation was the most frequently reported primary injury.
The study concluded that improved communication with patients and a higher surgical skill level could significantly reduce future claims.
Diabetes
Claims can often arise from mismanagement of patients with diabetes. In 2022 a study was undertaken into clinical negligence claims arising from diabetes and lower limb complications. The study identified the following:
- Failures to identify those patients that were high-risk and as such, those patients received minimal preventative care.
- Delays in and/or a failure to identify the extent and severity of pathology.
- Delays in the patient being seen by a specialist footcare team once a diagnosis was made.
- The assessments and treatments fell short of being evidence-based and care was unable to stop progression of the disease. Most patients were under a clinical team but outpatient interventions didn’t stop the need for emergency medicine or inpatient input.
- Lack of effective or standardised processes for admitting patients to hospital. Incomplete assessments, imprecise notes that didn’t have a clear meaning were also observed.
- Severe delays from the initial vascular assessment to the point of revascularisation.
- Imaging performed late in the progression of the pathology and poorly correlated to the clinical picture
- High levels of non-compliance but there was evidence of emotional and social factors and limited evidence of diabetic lower limb education provided.
The above are instances that could give rise to potential negligence cases resulting in amputation injury. In addition to these, there should always be careful consideration of management post-surgery and whether the patient has suffered any complications.
Complications following an amputation
Age, type of amputation and general health can all influence the risk of complications arising from an amputation. The risk of complication is lower in planned amputations than emergency ones. The following are common complications which may arise:
- Oedema of the residual limb may result in wound breakdown, pain, reduced mobility and difficulties with fitting a prosthetic.
- Wound infection can increase morbidity and have a negative effect on healing, phantom pain and the time to prosthetic fitting. Risk factors for infection can be diabetes, old age and smoking.
- Tissue necrosis
- Balance and stability issues due to loss of natural ankle
- Hair follicle infections
- Skin blisters
- Muscle contractures
- The spine may be affected because of altered gate and autonomic dysfunction.
- Osteomyelitis can sometimes be masked by deep and infected sinus.
- Pain including post-amputation pain, residual pain and phantom limb sensation.
Where a Claimant has suffered any of the above complications, consideration must be given to these and whether they have occurred as a result of negligence. For example, where wound breakdown or infection has occurred the post-surgical management should be investigated including whether regular wound inspection has occurred.
In addition to complications, co-existing pathology should be considered such as vascular pain, musculoskeletal pain and neuromas. There might also be prosthetic pain.
It’s important to consider complications and the effects of the same on a Claimant’s rehabilitation and/or use of their prosthetic. For example, there will be a period of time where a prosthetic cannot be used which in turn will impact on the Claimant’s care needs, their ability to work and accommodation requirements. Practitioners also need to have an awareness of and understand the treatments which are available and may assist in improving the condition.
References
- Hansrani, V. et al. Published in Annals of Vascular Surgery, vol 70, Jan 2021 https://pubmed.ncbi.nlm.nih.gov/
32946996/ - NHS Resolution (2022) Diabetes and lower limb complications: A thematic review of clinical negligence claims. NHS Resolution. Available at: https://resolution.nhs.uk/wp-content/uploads/
2022/06/Diabetes_and_Lower_Limb_Complications.pdf - StatPearls (n.d.) Lower Extremity Amputation. In: StatPearls [Internet]. NCBI Bookshelf. Available at: https://www.ncbi.
nih.gov/books/NBK546594/ - Physiopedia (n.d.) Complications Post Amputation. Physiopedia. Available at: https://www.physio-pedia.com/
Complications_Post_Amputation - NHS (n.d.) Amputation. NHS. Available at: https://www.nhs.uk/conditions/amputation/