Early admission of liability for breast cancer patient who required above knee amputation

Helen Thompson secured an admission of liability on behalf of a diabetic woman following a delay in diagnosing an ischaemic leg and foot caused by arterial blood clots caused by chemotherapy treatment for breast cancer at St Bart's Hospital.

The delay in diagnosis and treatment of the arterial blood clot resulted in the client requiring a high above knee amputation of the affected leg.

It is well-known that patients with cancer undergoing chemotherapy are at increased risk of developing blood clots, often in their lower limbs. National guidance recommends assessment for arterial thromboembolism if a person has symptoms suggestive of peripheral arterial disease or has diabetes, non-healing wounds on the legs or feet, or unexplained leg pain.

If peripheral arterial disease is suspected, NICE Clinical Guidelines state that the patient should be examined for evidence of critical limb ischaemia. This includes checking foot and leg pulses and measurement of the ABPI (Ankle Brachial Pressure Index) using a doppler probe.  

Following a diagnosis of bilateral breast cancer, Ms A was to receive neoadjuvant chemotherapy. Within six days of the first dose of chemotherapy in late December, Ms A started to complain of sudden onset, very severe and constant pain (which was not helped by strong painkillers), pins and needles and coldness in her left foot and shin. Ms A was unable to walk or weight bear on the foot due to pain.

Ms A contacted her GP, NHS 111 and the chemotherapy hotline at St Bart's Hospital which diagnosed post-chemotherapy pain.

Two days later, Ms A was seen in the Cancer Assessment Unit (CAU) at the hospital. The severe left foot and lower leg pain continued and the foot was noted to be cold. An X-ray of the foot was taken and was normal. A junior doctor queried whether investigations should be undertaken to check the blood flow in the left leg with a doppler or ABPI (as NICE guidance recommends) but this was overruled by a more senior doctor. If these investigations had been performed, an arterial blockage and reduced blood flow would have been identified. Ms A was prescribed oramorph and sent home.

A further week later, Ms A's left foot and lower leg pain was continuing despite very strong analgesia. She was assessed by a doctor in the CAU who diagnosed that Ms A's severe pain was due to gout. This diagnosis was made despite Ms A never having suffered with gout, without any investigations being carried out, a blood test for gout being normal and in the context of symptoms that were inconsistent with gout. Ms A was started on medication for gout which did not improve her pain or symptoms.

Over the course of the following 3.5 months, Ms A had further doses of chemotherapy. The pain and symptoms in her left foot and lower leg continued and became even worse to the point that Ms A was screaming out and crying in pain and unable to put any weight on the foot. The toes and parts of the left foot turned purple and then black in colour. Doctors in the Oncology Unit at St Barts Hospital continued to diagnose that she was suffering with gout. No further investigations were undertaken on the left leg, nor to check the diagnosis of gout.

Towards the end of April, four months after her left foot symptoms started, Ms A was seen by her GP who noted that due to the symptoms of a cold foot and severe pain she was unlikely to be suffering with gout and that it was likely to be a vascular issue. The GP referred Ms A as an emergency to Royal London Hospital.

A CT scan of her leg confirmed extensive thrombus within the left common iliac artery and left external iliac artery. This had significantly reduced blood supply to her left foot and lower leg which had caused her symptoms since January. Ms A's left foot was noted to be severely ischaemic with patches of necrosis.

A couple of days later, emergency surgery was performed to try and re-establish blood flow through the arteries and to the left foot. This surgery was unsuccessful and a scan a few days later showed no blood flow to the foot. Ms A's condition deteriorated and she underwent an above knee amputation a few days later.

The hospital Trust made a full admission of liability stating that Ms A's care should have been different from the first time she was assessed in CAU two days after the left foot pain developed. The Trust agreed that had it carried out or arranged further investigations from this time onwards, Ms A would have undergone specialist treatment and would have avoided the above-knee amputation.

Ms A and her family are left devastated by the errors in her medical care, that their concerns were repeatedly not listened to and the life-changing injury she sustained.

The claim will now be quantified and hopefully a swift settlement reached with the Trust.

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For further information about clinical negligence claims, and medical misdiagnosis claims please call Helen Thompson on 0330 460 6765 or email helen.thompson@fieldfisher.com.

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