These guidelines have been prepared by CREST

CREST is a small committee of doctors established under the auspices of the Central Medical
Advisory Committee, to promote clinical efficiency in the health service in Northern Ireland while
ensuring that the highest possible standard of clinical practice is maintained.

CREST wishes to express its appreciation to Mrs Mary Waddell and the working group for
producing this guidance, to all the members of the sub-groups and to all those who contributed
in any way to the development of these guidelines.

Special thanks are due to Mrs Heather Reid for the major contribution which she made to the
production of these booklets.
Further copies may be obtained from:
CREST Secretariat
Room 517
Dundonald House
Upper Newtownards Road
Belfast BT4 3SF

Tel: 028 90524391

CREST website
www.n-i.nhs.uk/crest

THE DIABETIC FOOT

Table of Contents
Foreword

Page

1.

Summary of Conclusions and Key Recommendations

2.

Introduction

3.

Current Provision of Care

4.

Pathology of Diabetic Foot Disease

5.

General Assessment

6.

Foot Examination

10

7.

Categories of Risk

12

8.

Treatment Guidelines

13

9.

Wound Management

14

10. Antibiotic Recommendations

15

11. Footwear Recommendations

18

12. Foot Reassessment

19

13. Education and Prevention Strategies

20

14. The Way Forward

22

Appendices
1.

Patient Education

23

2.

Referral Criteria

24

3.

Guideline Development Sub-Group

25

4.

CREST Wound Management Group

27

Useful Addresses

References:

28

A full list of references and further reading may be obtained by contacting the
CREST Secretariat.

Foreword
Early detection and surveillance of foot problems reduces the incidence of diabetic foot disease.
Poor management can be implicated in one third of the foot complications of diabetes mellitus,
resulting in very significant morbidity and mortality.
The St. Vincent Declaration includes targets for reducing the complications of diabetes.
Systematic and regular foot care has been shown to reduce the risk of chronic ulceration and
amputation in the lower limb by 50% or more. Admission for diabetic foot/leg disease is the
single largest component of hospital bed usage by people with diabetes. Almost half of all
diabetes related admissions are for lower limb disease.
The publication of this booklet offers assistance in diagnosis and therapy of the diabetic foot to
all health professionals.

1. SUMMARY OF CONCLUSIONS AND KEY RECOMMENDATIONS

A number of key recommendations highlighted throughout the report are listed below. Each
recommendation is graded so as to give the reader an indication of the type of evidence supporting it.
GRADE A
GRADE B
GRADE C

Requires at least one randomised controlled trial as part of the body of literature of overall
quality and consistency addressing the specific recommendation.
Requires availability of well conducted clinical studies but no randomised clinical trials on
the topic of recommendation.
Requires evidence from expert committee reports or opinions and/or clinical experience of
respected authorities. Indicates absence of directly applicable studies of good quality.

Grade
C

See Section
3

Improved co-ordination of primary and secondary care remains a

major priority for seamless and integrated quality care.

Neuropathy, ischaemia and infection are the processes involved

in tissue damage. Identification at an early stage can prevent
complications.

Risk factors for potential foot problems can be identified from the
history and laboratory investigations.

Foot examination and screening should be carried out by

professionals with specific foot care training.

Palpation of pedal pulses can be unreliable in assessing

ischaemia. All patients should have Ankle Brachial Pressure
Index (ABPI) recorded, with an acceptable range being 0.8 - 1.2.

Vibration perception threshold greater than 25 volts carries a

seven fold increase in ulceration risk. All patients should have
objective sensory assessment.

The presence of callus in a neuropathic foot carries a nine fold

increase in ulceration risk.

Accumulating risk factors result in a significant increase in

amputation risk.

Treatment guidelines should be used to assess the risk of foot

complaints in patients with diabetes.

Necrotic digits without infection should be kept dry and left to

separate naturally. However the presence of infection is a
contraindication to this conservative management.

9.1

Sharp debridement of the diabetic foot ulcer in the community

should only be carried out by an experienced state registered
podiatrist.

9.1

Care should be taken to reassess ulcers frequently as

progression from superficial to deep ulceration can occur rapidly
without significant symptomatic change.

10.1

After microbiology results become known, therapy should be

adjusted to specific antibiotics directed for the causative
pathogenic micro-organisms. However, the organisms identified
by microbiology may not necessarily be the causative pathogen.
Each situation should be judged in the light of clinical progress.

10.1

Osteomyelitis is a frequent and serious complication of diabetic

foot disease. Under-diagnosis and difficulty in diagnosis is
common.

10.2

Bony x-rays should always be obtained, but conclusive x-ray

evidence of osteomyelitis may not be present and is not always
necessary for diagnosis or treatment.

10.2

The presence of bone at the base of an ulcer on probing by an

experienced state registered podiatrist will indicate osteomyelitis.

10.2

All patients with diabetes should have properly fitting appropriate

shoes.

11

Trainer footwear can be worn by patients who have foot

deformity.

11

Patients with diabetes who smoke cigarettes have a significantly

increased risk of ulceration and gangrene.

13.2

Good patient education has shown significant benefits in

prevention of diabetic foot ulcers and in the reduction of
amputation rates.

13.2

Multidisciplinary team care has been shown to significantly

reduce amputation rates in diabetic patients.

14.4

2. INTRODUCTION
2.1

Foot complications in people with diabetes are common, accounting for almost half of all
diabetes-related admissions in the United Kingdom. In community-based surveys, the
prevalence of foot ulceration among people with diabetes at any point in time has been
shown to be 3-4%, whilst the overall incidence of foot complications in the diabetic
population is 5-10%.

2.2 Patients with diabetes can develop foot problems related to neuropathy, arterial disease or
infection. Any element in this triad can be present, and can lead to tissue necrosis,
cellulitis, ulceration or gangrene. The relative role played by each element can vary, but
community studies have shown that of these patients with diabetic ulceration, 40% were
associated with neuropathy alone, 25% with arterial disease predominantly, whilst 35%
had both neuropathy and vascular disease.
2.3 Amputation affects 1.3% of all patients with diabetes. In Northern Ireland 60% of all major
amputations are related to diabetes. The risk for the patient with diabetes of undergoing
major amputation is 15 times greater than for the non-diabetic population.
2.4 The St Vincent Declaration was formulated following an initial meeting of government
bodies, health organisations, diabetic groups and carers in 1989. This established a series
of recommendations for improving health care in diabetes. In response to this Declaration,
the Department of Health and the British Diabetic Association set up a UK Joint Task
Force for Diabetes, with observers from Scotland, Wales and Northern Ireland. This group
in turn established Specialist Advisory Subgroups for certain priority areas. The Diabetic
Foot and Amputation Subgroup was charged with assessing the prevention of foot
complications in patients with diabetes. The full report of the subgroup was published in
July 1995.
2.5 In May 1994 CREST organised a conference in Northern Ireland and from this established
a Northern Ireland Task Force to consider local implementation of the St Vincent
Declaration. The Northern Ireland Report was circulated in August 1996. One of the main
recommendations in the report was the production of local clinical guidelines to ensure
timely referral to specialist services.
A CREST Diabetic Foot Group was established to draw up local management guidelines
for foot care in patients with diabetes.
2.6 This document represents a consensus view on the assessment and management of the
diabetic foot in both primary and secondary sectors in Northern Ireland. The Group have
been guided by current research, by evidence from clinical practice and by an assessment
of what is realistically achievable within the resources available.

3. CURRENT PROVISION OF CARE

The division of care between primary and specialist care depends on the level of expertise of
practitioners, patient choice and the complexity of the individual case. Accordingly, patients with
diabetes may attend their GP, a hospital clinic(s) or both. In both settings, care is undertaken by
multiprofessional teams.
Improved co-ordination of primary and secondary care
remains a major priority for seamless and integrated quality
care.

4. PATHOLOGY OF DIABETIC FOOT DISEASE

There are three main factors involved in the pathology of the diabetic foot.
1. Neuropathy leading to sensory deficit and autonomic dysfunction. The foot is warm, numb,
dry and usually painless with palpable pedal pulses. The two main complications seen are
the neuropathic ulcer which is found mainly on weight bearing areas and the neuropathic
(Charcot) joint.
2. Ischaemia results from atherosclerosis of the leg vessels. In the person with diabetes it is
often bilateral, multisegmental and distal, involving arteries below the knee. The
neuroischaemic foot is cool and pulses are absent. It is complicated by pain at rest,
ulceration on the margins of the foot and gangrene of the digits.
3. Infection is often polymicrobial. It can spread rapidly causing overwhelming tissue
destruction. Such damage is the main cause of amputation in the neuropathic foot.
Thus the foot goes through three stages in its natural history:
(i) no evidence of neuropathy or peripheral vascular disease;
(ii) evidence of neuropathy and/or peripheral vascular disease and therefore at risk of
developing complications;
(iii) established complication of neuropathy and/or peripheral vascular disease and therefore
risk of amputation.
Amputation is not inevitable. Early recognition of the at risk foot, the prompt institution of
preventative measures, and the provision of rapid and intensive treatment of foot complications
in multidisciplinary foot clinics has reduced the number of amputations in patients with diabetes.
Neuropathy, ischaemia and infection are the processes
involved in tissue damage. Identification at an early stage can
prevent complications.

Examples of Diabetic Foot Pathology

At Risk Foot
lateral planter callus, dystrophic nails, MTP joint deformity.

Haemorrhagic Callus conceals sub callosity ulcer.

Neuropathic plantar ulcer with callus formation.

Neuroischaemia with digital gangrene on 5th toe and

apical ulcer hallux ulceration.

Sausage Toe digital ulceration with underlying

osteomyelitis.

Infection Tracking Ulcer following minor puncture

with a nail.

Deep Foot Abscess cellulitis and gangrene following

digital cleft infection.

Charcot Feet

5. GENERAL ASSESSMENT
(i) General Medical History:
A full and complete medical history should be obtained from the patient. During this
initial assessment specific risk factors for potential foot problems must be identified.
These include:

history of macrovascular disease e.g. coronary heart disease and peripheral vascular
disease;

smoking;

hypertension;

medication history;

previous foot ulceration;

poor eyesight;

poor social status;

poor nutritional status;

body mass index (BMI).

(ii) History of Diabetes:

duration of diabetes;

history of microvascular complications e.g. retinopathy.

(iii) Investigations:

blood glucose;

HbA1 / HbA1c;

plasma lipids and lipoproteins;

creatinine;

microalbuminuria;

ECG.

Risk factors for potential foot problems can be identified from

the history and laboratory investigations.

6. FOOT EXAMINATION

Foot examination and screening should be carried out by

professionals with specific foot care training.

Palpation of pedal pulses can be unreliable in assessing

ischaemia. All patients should have Ankle Brachial
Pressure Index (ABPI) recorded, with an acceptable range
being 0.8 - 1.2.

Vibration perception threshold greater than 25 volts

carries a seven fold increase in ulceration risk. All patients
should have objective sensory assessment.

The presence of callus in a neuropathic foot carries a nine

fold increase in ulceration risk.

Screening should be carried out by a trained health care professional (podiatrist, practice nurse,
doctor, diabetes nurse specialist, clinic nurse). This should include:
(i) Symptoms:

claudication;

cold feet;

previous ulceration;

numbness;

pain;

paraesthesia.

(ii) Inspection:

gait;

deformities of feet;

check nails for adequate care, sepsis or abnormality;

pressure area e.g. bunions, retracted toe;

callus formation;

check between toes for integrity of skin.

10

(iii) Vascular status:

note skin temperature;

pulses (posterior tibial and dorsalis pedis. If absent, check femoral and popliteal);

Ankle Brachial Pressure Index (ABPI).

(iv) Sensory Assessment:

10g monofilament;

neurotip;

neurothesiometer or biothesiometer provides the best available objective assessment of the

progression of neuropathy.

(v) Footwear Assessment:

good fit;

breathable material;

shoe style;

condition of shoe.

Practical footwear recommendations may be found in section 11.

11

7. CATEGORIES OF RISK FOR ULCERATION/AMPUTATION

GENERAL

LOCAL

ISCHAEMIA

NEUROPATHY

Smoking
Hyperglycaemia
Hyperlipidaemia
Old age
Duration of diabetes
Proteinuria
Poor social status
Retinopathy
Previous ulceration
Poor nutritional
status

Nails
Oedema
Callus
Deformity
Footwear
Hosiery
Limited joint mobility
Trauma

Absent peripheral
pulses
ABPI <0.8 or >1.2

Dry skin
Loss of 10g
protective sensation
Neurothesiometer
reading 25V+
Existing Charcot foot

Accumulating risk factors result in a significant increase in

amputation rate.

12

8. TREATMENT GUIDELINES FOR THE MANAGEMENT OF THE

DIABETIC FOOT

13

9. WOUND MANAGEMENT
The principles for selecting an ideal wound dressing described in the CREST document
Guidelines on the General Principles of Caring for Patients with Wounds should be followed:

provide a moist wound environment;

manage excess exudate;
allow gaseous exchange;
provide a constant wound interface temperature;
protect the wound from pathogenic organisms;
protect the wound from particulate matter and chemical damage;
protect the wound from trauma.

Note: Wound dressings for the diabetic foot ulcer should not be too bulky or the shoe fit will be
compromised.
9.1 Management
Management of the diabetic foot ulcer follows the general management guidelines for a
necrotic, sloughy, infected, granulating and epithelialising wound, as outlined in the CREST
General Principles document.
Several specific points regarding diabetic footcare need to be emphasised:

Patients with diabetes have a delayed and reduced inflammatory response therefore
the normal signs of the infected wound may not be present;

All dressings described in the Crest General Principles document are suitable for the
management of the diabetic foot;

Frequency of dressing change must be based on careful assessment of the

neuropathic and vascular status of the foot.

Newer technologies, such as topical application growth factors and tissue engineered products
have been used in the treatment of the diabetic foot ulcer. To date the evidence supporting the
use of these products is limited. Future research must include economic analysis.

Necrotic digits without infection should be kept dry and

left to separate naturally. However the presence of
infection is a contra-indication to this conservative
management.

Sharp debridement of the diabetic foot ulcer in the

community should only be carried out by an experienced
state registered podiatrist.

14

10. ANTIBIOTIC RECOMMENDATIONS

The pathogenic micro-organisms are often unknown when antimicrobial therapy is initiated. The
spectrum of the prescribed antibiotic should be broad spectrum in order to cover the possible
causative organisms. Knowledge of the likely causative organisms is therefore important. These
are presented in a schematic fashion using the Wagner classification.

15

10.1 Empiric antibiotic recommendations for a clinically infected ulcer

(i) Superficial ulcer
Flucloxacillin 500mg qds}
OR
Co-amoxiclav 625mg tds}

for 7-14 days with frequent

reassessment

(ii) Deep ulcer

Flucloxacillin 500mg qds}
Ciprofloxacin 500mg bd}
Metronidazole 400mg tds}

triple therapy regimen

Duration of therapy depends on the severity of the ulcer but generally

should be considered for 6 weeks.
(iii) Deep ulcer plus active cellulitis
Regimen as above but i.v. antibiotics essential, usually based on
sensitivity testing.If required, seek advice from medical microbiologist.
Note: For patients with a penicillen allergy
Erythromycin 500mg qds.
OR
Clarithromycin 500mg bd.
For treatment failure, active cellulitis or osteomyelitis, microbiological advice
should be sought for further alternative treatment regimens.

After microbiology results become known, therapy should

be adjusted to specific antibiotics directed for the
causative pathogenic micro-organisms. However, the
organisms identified by microbiology may not necessarily
be the causative pathogen. Each situation should be
judged in the light of clinical progress.

Care should be taken to reassess ulcers frequently as

progression from superficial to deep ulceration can occur
rapidly without significant symptomatic change.

16

10.2 Osteomyelitis

Osteomyelitis should be strongly suspected in ulcers persisting for 8 weeks or longer.

Osteomyelitis is a frequent and serious complication of

diabetic foot disease. Under diagnosis and difficulty in
diagnosis is common.

Bony X-rays should always be obtained, but conclusive Xray evidence of osteomyelitis may not be present and is
not always necessary for diagnosis or treatment.

The presence of bone at the base of an ulcer on probing

by experienced podiatry staff will indicate osteomyelitis.

Osteomyelitis should be immediately referred to hospital.

10.3 Recommendations for Amputation

Minor or major amputations should never be carried out without prior vascular surgery
assessment. In general the only indications for amputation are intolerable pain, progressive
gangrene or septic/toxic conditions not responding to medical treatment.

17

11. FOOTWEAR RECOMMENDATIONS

It is essential that patients have properly fitting shoes to help prevent the development of
pressure sores and ulcers. Foot ulcers in patients with diabetes are commonly caused by poorly
fitting shoes. Suitable footwear needs to follow these general guidelines.
i)

The natural outline of the foot should be followed by the shoe. The shoe should fit snugly,
and not be too tight.

ii)

Shoes should have a deep enough toe-box to accommodate any deformity.

iii)

Shoes should have a soft heel counter that will keep the foot in place.

iv)

The shoe upper should be made of leather or other breathable material. The leather over
the fore foot should be as soft as possible.

v)

There should be approximately a 15mm gap between the tip of the big toe and the toebox.

vi)

The inside lining of the shoes should be smooth and free from seams and/or wrinkles.

vii)

The style of the shoe is important. It is crucial that the shoe has a secure fastening
mechanism, laces being the most desirable.

viii) The shoe should have a heel height that is not excessive (25-30mm).
Patients should be advised to change their shoes twice daily and to ensure that they are in a
good state of repair and checked for any foreign objects before they are put on. New shoes
should be bought in the afternoon when the feet and ankles are at their most swollen and
should be worn gradually for an increasing period every day. New shoes should never need to
be broken in.
Trainer footwear can be worn for patients with a minimal amount of foot deformity provided they
have sufficient room at the forefoot.
Patients at low or medium risk of ulceration, should have their footwear reviewed every 3 - 6
months. If necessary, the patients own footwear can be orthotically modified to reduce the
likelihood of ulcer development. If the patient is unable to obtain suitable footwear or has very
deformed feet then footwear may need to be requested with specially designed insoles. The
importance of wearing prescribed footwear and insoles must be emphasised to patients.

18

Socks should fit well. A loose fitting sock may wrinkle and lead to skin injury. Socks which cause
a compression of 9-12mmHg are desirable for patients with diabetes. Good quality sports socks
can provide this compression but, thicker socks may make fitting of shoes more difficult.

All patients with diabetes should have properly fitting

appropriate shoes.

Trainer footwear can be worn by patients who have

minimal foot deformity.

12. FOOT REASSESSMENT

For diabetic patients without current foot complications a review strategy should include the
following.

Investigation

Frequency

Ankle Brachial
Pressure Index

Annual

Neurothesiometer
(VPT)

Annual

10g Monofilament

Annual

Footwear Review

3-6 Monthly

Note: for patients with complications see the review strategy as outlined in section 8.

19

13. EDUCATION AND PREVENTION STRATEGIES

13.1 General Patient Education
(i) Smoking
Smoking significantly increases mortality in people with diabetes. People with diabetes who
smoke have an increased risk of foot complications and are more likely to present with
gangrene and ulcers. All patients with diabetes should be encouraged to stop smoking
immediately.
(ii) Nutrition
Optimising overall nutritional status is an effective way to improve the status of wounds. Poor
nutrition leading to nutrient deficiencies and poor glycaemic control, may delay the healing
process and may reduce the integrity of tissues. The diet should be varied and balanced to
provide all the essential nutrients and to promote good glycaemic control and wound healing.
Patients at risk of poor nutritional status should be referred to a state registered dietitian (see
Appendix 2).
(iii) Exercise
Exercise/activity is beneficial for people with diabetes. Those with peripheral vascular disease
and/or neuropathy are encouraged to be as active as possible. Appropriate footwear must be
used and feet should be inspected after exercise.
(iv) Alcohol
Alcohol may be consumed in moderation. Men should drink no more than 21 units and women
14 units each week (1 unit = half a pint of beer or one glass of wine).
13.2 Specific Footcare Education
The key to the prevention of foot problems in patients with diabetes is education in good foot
care.
Education should:

be tailored to the individual;

have a content appropriate to the particular risk group;

be regularly repeated and reinforced;

emphasise the need for urgent expert assessment.

20

There are three main education target groups:

(i)

those who are fit and whose feet are at low risk;

(ii)

those whose feet are at higher risk but who are otherwise fit and lead active lives;

(iii)

the frail patients with feet at high risk who are largely dependent on others.

(i) Patients who are fit and whose feet are at low risk should:

observe simple foot hygiene;

check for fungal infection;

be given an explanation of the role of neuropathy and vascular disease;

appreciate the importance of annual screening;

know how to access the service.

(ii) Patients with higher risk feet should, in addition, be advised:

how to minimise the likelihood of problems;

the importance of the reduction of callus by the podiatrist;

footwear and hosiery recommendations.

(iii) Advice on footcare should be given to the carers of frail, dependent patients with at
risk feet.
Detailed patient education information may be found in Appendix 1.

Patients with diabetes who smoke cigarettes have a

significantly increased risk of ulceration and gangrene.

Good patient education has shown significant benefits in

prevention of diabetic foot ulcers and in the reduction of
amputation rates.

21

14. THE WAY FORWARD

All people with diabetes in the province can be regarded as being at risk of diabetic foot complications.
Diabetic care can be provided in the hospital setting and in the community or in shared/integrated
arrangements. Ideally both systems should have clearly defined points of access and clear criteria for
further referral. Care provided in multidisciplinary teams has been shown to have significant advantages
for patients and as far as possible all models should be team-based. There is also good evidence that
access to podiatry care at all levels is an essential part of good management and the improvement of
patient outcomes.

14.1 Hospital Management Team

This group should be based in a unit with a physician with a special interest in diabetes. The team
should include:

physician;
podiatrist;
surgeon, with an interest in diabetic vascular surgery;
orthotist, for the provision of foot wear and orthoses;
specialist diabetic nurse;
dietitian;
hospital pharmacist, with an interest in diabetes / wound management;
microbiologist.

14.2 Community Management Team

This group is based in general practice, ideally with a general practitioner who has a special interest in
diabetes. The team should include:

general practitioner;
podiatrist;
specialist diabetic nurse / practice nurse / district nurse;
dietitian;
community pharmacist / practice pharmacist.

Both Hospital and Community Management Teams may access the services of Occupational Therapy,
Physiotherapy, Orthopaedic Surgery, and Clinical Psychology in providing optimum care for patients.

14.3 Podiatric Care

All patients with diabetes must have access to podiatric care within the integrated management team.

14.4 Diabetes Register

An information infrastructure is essential for measuring and monitoring the effectiveness of services and
the health of patients with diabetes. To achieve this, there is a need for the setting up of diabetic
registers at board level for people with diabetes as recommended by the CREST Diabetes Care in
Northern Ireland document (June 1996).
Multidisciplinary team care has been shown to significantly reduce
amputation rates in diabetic patients.

22

Appendix 1: PATIENT EDUCATION INFORMATION

1. Basic footcare advice
(i) Foot hygiene:

daily bathing and washing of the feet using a mild soap and lukewarm
water.

(ii) Nail care:

nails should be cut to the shape of the end of the toe.

(iii) Skin care:

skin should be moisturised after bathing (except between the toes).

There should be no self treatment of corns and callus.

(iv) Heat and cold:

avoid extremes of temperature.

(v) First Aid:

a sterile dressing should be applied and advice sought if the area does
not heal within a few days.

(vi) Footwear:

see Section 11

2. Specific advice for patients with neuropathy/ ischaemia

In addition to the basic footcare advice, further information should be provided regarding:
(i)

daily inspection of feet;

(ii)

use of footwear when walking;

(iii)

the checking of shoes and socks before putting them on;

(iv)

accessing the foot care service;

(v)

the importance of the reduction of callus by the podiatrist;

(vi)

the recognition of the warning signs of foot problems;

(vii)

the recognition of infection.

23

APPENDIX 2: REFERRAL CRITERIA

1. Referral to podiatry services:
The podiatrist in the community foot care team should see:

all patients with calluses;

all patients with a foot deformity;
all patients with foot ulceration;
all patients with nail pathologies.

2. Referral to the hospital diabetic foot team:

a] Routine referral:

patients with ischaemia (ABPI < 0.8, > 1.2);

patients with neuropathy and callus/foot deformity;
patients with end stage renal failure (dialysis or transplantation).

b] Urgent referral:

patients with infection in the presence of foot deformity, callus,

ischaemia or neuropathy;
suspected acute or chronic Charcot joint;
any ulcer present for longer than 8 weeks.

3. Referral to the vascular team:

All patients with ischaemia and diabetes should be referred to the hospital management
team and should have a vascular assessment carried out.
Urgent referral direct to a vascular surgical team is necessary for acute ischaemia or
uncontrolled sepsis.
4. Referral to the orthotist:
Referral to the orthotist is usually via one of the following routes:

Podiatrist referral to GP;

GP referral to Diabetic clinic;
GP referral to appliance officer of local hospital;
direct consultant referral.

24

APPENDIX 3 Guideline Development Sub-Group

Dr John Andrews
(Chairman)

Consultant Physician
United Hospitals Trust

Ms Jackie Campbell

Senior Podiatrist
Newry and Mourne Health and Social Services
Trust

Dr Vanessa Chambers
(Secretariat)

Pharmacist, DHSS

Miss Jill Cundell

Chief Podiatrist
Homefirst Community Trust

Dr P.J. Fox

General Practitioner
Ballymena Health Centre

Mr Paul Gawley

Orthotist, Bullen Healthcare

Musgrave Park Hospital

Mrs Dianne Gill

(Co-ordinator)

Pharmacy Services Manager

United Hospitals Trust

Professor Randal Hayes

Consultant Physician
Belfast City Hospital Trust

Mrs Marilyn Higgin

Specialist Health Visitor

Belfast City Hospital Trust /
South & East Belfast Community Trust

Mr Bernard Lee

Consultant Vascular Surgeon

Belfast City Hospital Trust

Dr Kenneth Moles

Consultant Physician
Altnagelvin Hospitals Trust

Miss Alyson Moore

Chief Dietitian
Royal Hospitals

Mrs Bronagh Monaghan

Chief Podiatrist
Belfast City Hospital Trust

25

Appendix 4 CREST WOUND MANAGEMENT GROUP

Mrs Mary Waddell
[Chairman]

Director of Nursing
Eastern Health & Social Services Board

Dr John Andrews

Consultant Physician
United Hospitals Trust

Mrs Lilian Bradley

Leg Ulcer Advisor

Ulster Community & Hospitals Trust

Miss Jackie Campbell

Senior Podiatrist
Newry & Mourne Trust

Dr Vanessa Chambers

Pharmacist
DHSS

Mrs Janette Collins

Dermatology Ward Sister

Craigavon Area Hospital Group Trust

Mrs Dawn Connolly

Research Project Nurse

Craigavon Area Hospital Group Trust

Miss Jill Cundell

Chief Podiatrist
Homefirst Community Trust

Mrs Jeannie Donnelly

Tissue Viability Nurse

Royal Hospitals

Dr Brid Farrell

Consultant in Public Health

Southern Health & Social Services Board

Dr Colin Fitzpatrick

Medical Advisor
Eastern Health & Social Services Board

Dr PJ Fox

General Practitioner
Ballymena Health Centre

Mr Paul Gawley

Orthotist, Bullen Health Care

Musgrave Park Hospital

Mrs Dianne Gill

Pharmacy Services Manager

United Hospitals Trust

Mr Stephen Guy

Pharmacist
Royal Hospitals

Professor Randal Hayes

Consultant Physician
Belfast City Hospital Trust

Mrs Marilyn Higgin

Specialist Health Visitor

Belfast City Hospital Trust/ South & East Belfast Community
Trust

Dr Carmel Hughes

Lecturer, School of Pharmacy

Queens University, Belfast

Dr Hilary Jenkinson

Consultant Dermatologist
United Hospitals Trust

Mrs Kay Kane

Nurse Manager, Community Nursing

South & East Belfast Community Trust

26

Dr James Kelly

Consultant Physician
Sperrin Lakeland Trust

Mr Bernard Lee

Consultant Vascular Surgeon

Belfast City Hospital Trust

Dr Jill Mairs

Regional Procurement Pharmacist

Eastern Health & Social Services Board

Dr Carolyn Mason

Assistant Director of Nursing

Eastern Health & Social Services Board

Dr Barry Mitchell

General Practitioner
Lodge Health, Coleraine

Ms Andre McCollum

Director of Pharmaceutical Services

Eastern Health & Social Services Board

Miss Alyson Moore

Chief Dietitian
Royal Hospitals

Mrs Elizabeth Moore

Senior Dietitian
Royal Hospitals

Dr Kenneth Moles

Consultant Physician
Altnagelvin Hospital Trust

Mrs Bronagh Monaghan

Chief Podiatrist
Belfast City Hospital Trust

Mrs Mary OHare

Research Pharmacist
Royal Hospitals

Mrs Heather Reid

Project Manager
Eastern Health & Social Services Board

Dr Keith Steele

General Practitioner
Dunluce Health Centre, Belfast

Ms Kathryn Turner

Pharmaceutical Advisor
Eastern Health & Social Services Board

Dr Jane Whiteman

Senior Pharmacist
Greenpark Health Care Trust

Mrs Anne Witherow

Tissue Viability Nurse

Altnagelvin Hospital Trust

Miss Ruth Woodmartin

Chief Dietitian
Greenpark Health Care Trust

CREST REPRESENTATION
Dr Philip McClements

Deputy Chief Medical Officer, DHSS

Convenor of CREST

CREST SECRETARIAT

Miss Angela Lowry

Mrs Isobel Scott
Mr Gary Hannan

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Information on local British Diabetic Groups may be obtained from:-

Diabetes UK
John Gibson House
257 Lisburn Road
Belfast
Tel: 028 90666646

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