Recurring concern

Failure to assess and respond to limb viability concerns

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First reported 2 Oct 2014•Latest report 18 Jun 2025

Definition

What this concern includes

Includes failures of clinical examination, focused limb-viability checks, monitoring, recognition, referral, escalation or other dedicated controls concerning possible limb compromise, including abnormal swelling, temperature, pain, wounds, inability to mobilise or other relevant findings.

Not included

  • Excludes generic clinical assessment or monitoring failures where limb viability or a material limb-specific concern is not identified.
  • Excludes general wound-management, fracture-management or vascular-disease concerns unless the asserted deficiency concerns assessment or response to possible limb compromise.
  • Excludes failures limited to documentation, staffing, training or communication unless they directly result in an unreliable limb-viability assessment or response process.
  • Excludes unrelated lower-limb risks such as venous thromboembolism where no failure to assess or respond to limb viability concerns is asserted.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Alexandra & Crestview Surgeries1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Nursing and Midwifery Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Suffolk

    AI-generated summary

    Terence COLBY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Terence COLBY died on 27 September 2023 after critical limb ischaemia led to a below-knee amputation, followed by hospital-acquired pneumonia and a pulmonary embolism. The principal concern was that his GP practice failed to undertake a simple vascular examination despite a foot wound and leg pain, which was described as substantially sub-standard practice and contrary to national guidelines.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to undertake vascular examination of a limb when a foot wound and leg pain are reported

    Wider context from the report

    “During the Course of the Inquest evidence was received in the form of a Report from an Expert in General Practice, commissioned by the Court and which considered the care and treatment provided to Mr. COLBY by his GP Practice (Alexandra & Crestview Surgeries, Lowestoft). The Report highlighted substantially sub-standard practice provided to Mr. COLBY on the 17th August 2023 by Alexandra & Crestview Surgeries. This was as follows: On 17th August 2023, despite the presence of a wound on the foot and the report of leg pain, there was a failure by the examining GP to undertake a simple vascular examination of Mr. COLBY’S limb. The Expert Report highlighted that this was despite the fact that “As per the NICE guidance already quoted, peripheral arterial disease needed to be considered here and this was a patient who had attended face to face. In my view this was substantially sub-standard practice and a failure to provide basic medical care (failure to examine) and was against national guidelines.” Although the Inquest did not conclude that the failure identified above was causative of Mr. COLBY’s death, I am concerned that should such practice continue, without remedial action, then there is a risk of future death in other patients. ”

    Source location

    Terence COLBY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Hold a multidisciplinary learning event reviewing peripheral vascular disease, differential diagnosis of foot and lower-limb pain, clinical assessment, red flags and referral criteria.

    Verbatim wording from the response

    “Unfortunately, ████████ is no longer member of staff at this surgery. I understand that she is going to give a response on your invitation to do so. However having reviewed the case of Mr Terence Colby, we feel it would be useful to review the presentation of patients with peripheral vascular disease and consider differential diagnosis of ‘foot and lower limb pain’. We are planning on having a learning event when we will discuss the history, presentation, clinical examination, investigation, and referral criteria particularly when there are red flags which become evident.”

    Source location

    Response from Alexandra & Crestview Surgeries
    Page 2 · response
    Published 3 July 2025

    Open published response

  2. Inner South London

    AI-generated summary

    Mr Royston Kemp · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Royston Kemp, an 85-year-old care home resident with dementia and a history of fractures and falls, suffered an unwitnessed traumatic fracture of his left femur in February 2016. He was not referred to hospital until two days after signs of injury and died on 20 March 2016 from pneumonia, aspiration and advanced dementia, with the fracture-related immobility identified as a key contributor. Concerns included failure by a nurse to act on leg swelling and temperature differences, establish the care assistant’s concerns, measure vital signs, or escalate for medical assessment and referral.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to act on abnormal limb findings

    Wider context from the report

    “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was: 1) She found one leg more swollen than the other and of a different temperature but took no action 2) She failed to establish the care assistant’s concern or whether she had met the concern before or after her assessment 3) She failed to measure Vital Signs 4) She failed to escalate to medical care or refer, in the process failed to enable a diagnosis of fractured femur to be made. ”

    Source location

    Mr Royston Kemp · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. London (East)

    AI-generated summary

    Mr Pether · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Pether was admitted after a fall that caused a right femur peri-prosthetic fracture, with a pre-existing infection and an open fracture increasing the risk of infection. Transfer for complex surgery was delayed, and records identified no focused medical or nursing checks of limb viability between 11 and 20 December 2012. The wound was found to be infected and necrotic on 20 December; despite surgery, amputation and intensive care, Mr Pether deteriorated and died from left ventricular failure after developing multi-organ failure.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct focused checks of limb viability

    Wider context from the report

    “1. Despite the clear risk of infection in Mr Pether’s wound there were no medical record entries by the orthopaedic medical team or nursing team on Amber ward, of any focussed checks upon the viability of Mr Pether’s limb between the 11 December and the 20 December 2012. This would appear to be a very basic standard of care required on an orthopaedic ward. ”

    Source location

    Mr Pether · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026