An NHS patient could lose her toe after it became infected with gangrene following surgery to remove part of her nail, due to failings by a London NHS trust. An investigation found several failures in the care provided by the Central London Community Healthcare NHS Trust, which serves 14 London boroughs including Brent, Hillingdon, Westminster and Kingston as well as Hertfordshire.
The woman, who has been kept anonymous, was a known diabetic attending the podiatry service since 2015. She attended her local Podiatry Team in severe pain with a blackened toenail with an ulcer underneath on January 16 last year. A section of her toenail was removed and the patient was prescribed antibiotics by her GP.
Pain worsened and toe became gangrenous
However her pain worsened and circulation to her toe deteriorated until it became gangrenous. The patient and her daughter visited the podiatry service multiple times where she complained about being in "excruciating" pain. In mid-March 2025, she was admitted to St Mary's Hospital in Paddington where she was given vascular intervention — a procedure to treat diseases of the blood vessels.
The patient is now living with ongoing pain, waiting for her toe to either 'self-amputate' — fall off on its own — or to be surgically removed. The incident is detailed in NHS Board papers being discussed at a meeting on Thursday (September 24).
Investigation found missed opportunities
A Patient Safety Incident Investigation found that no assessment was carried out to check if there was enough blood flow to the toe to safely perform surgery. The team also went ahead with the procedure without conducting a preoperative assessment or getting written consent.
“This investigation found that the patient experienced harm due to missed opportunities to recognise and act on worsening blood flow to the foot,” reads the report. “Although the patient had diabetes and a history of vascular risk factors, key assessments were not completed or documented at critical points, particularly when the patient presented with severe pain, colour change, and ulceration of the right big toe.”
The patient and her daughter reported feeling “distressed, unheard and uncertain” that their concerns were being taken seriously. Further issues were identified, such as failure to review her diabetic foot classification, failure to escalate to specialist vascular services, incomplete and inconsistent clinical paperwork and problems with the clinical environment.
Trust apologises and introduces new measures
“These failures contributed to a delay in identifying the severity of peripheral arterial disease, leading to chronic limb-threatening ischaemia, gangrene of the toe, and the need for urgent hospital treatment,” the report adds. A spokesperson for the trust said: “The incident took place in January 2025. In response, we introduced mandatory pre-surgery assessments, strengthened our procedures to ensure concerns are escalated promptly, and enhanced training and competency checks for all podiatrists to improve patient safety. Discussions took place with the patient and their family and we offered our sincere apologies.”
