Patient faces possible toe loss after podiatry errors, NHS Board to review case
A diabetic woman’s toe became gangrenous following a nail removal in January 2025, prompting a safety investigation and upcoming board discussion on 24 September 2026
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A diabetic woman, who has been using the local podiatry team since 2015, presented on 16 January 2025 with a discoloured big toe and an ulcer underneath. The podiatry team removed part of the nail and her GP prescribed antibiotics. Her pain intensified and the toe’s colour changed, indicating reduced circulation.
Investigation findings
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MyLondon reported that a Patient Safety Incident Investigation concluded the clinic did not carry out a pre‑operative assessment of arterial blood flow before the nail removal. The report also noted the absence of written consent and a failure to document key assessments despite the patient’s known diabetes and vascular risk factors.
"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."
Trust spokesperson, Central London Community Healthcare NHS Trust
Trust response
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The spokesperson for Central London Community Healthcare NHS Trust, as quoted by MyLondon, said the trust has now made pre‑surgery assessments compulsory for all podiatry procedures. Training programmes have been updated and a new escalation pathway to vascular specialists has been put in place. The trust also offered an apology to the patient and her family.
Next steps
The incident will be examined in NHS Board papers at a meeting scheduled for 24 September 2026, according to MyLondon. The board will consider the investigation report and the trust’s remedial actions. No further details on potential disciplinary measures or compensation have been released.
Questions this report answers
+What went wrong with the podiatry treatment?
The investigation found that clinicians did not assess blood flow to the toe before removing part of the nail and did not obtain written consent. Those omissions meant worsening circulation was not recognised, leading to gangrene and the need for urgent hospital care.
+When will the incident be discussed by the NHS Board?
The case will be examined at an NHS Board meeting on 24 September 2026, as reported by MyLondon. The board will review the investigation findings and the trust’s response, though the outcome of that discussion has not yet been disclosed.
+What actions has the trust taken after the investigation?
The trust introduced mandatory pre‑surgery assessments for podiatry, updated training and competency checks for podiatrists, and created a clearer escalation route to vascular specialists. It also issued an apology to the patient and her family, according to MyLondon.
+What is the patient’s current condition?
After being admitted to St Mary’s Hospital in mid‑March 2025 for vascular intervention, the patient remains in pain and is awaiting either natural loss of the toe or surgical removal. The situation continues to be monitored as part of her ongoing care.
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