We have settled a case for delayed diagnosis of Cauda Equina Syndrome against Hampshire Hospitals NHS Foundation Trust. Our client, a new mother, attended A&E complaining of numbness and a burning sensation from the waist down. She was also suffering from increased urinary frequency, with an altered sensation when she passed urine.
She was given a cursory examination by an emergency nurse practitioner (ENP), who diagnosed sciatica, and discharged her. No instructions for “red flag” symptoms were discussed. The woman then returned home, and the next morning collapsed in the shower. By this stage she had also lost urinary and bowel function. She was taken by ambulance to a different hospital, where the diagnosis of Cauda Equina Syndrome was made. Overall there was a delay of some 24 hours before the correct diagnosis was reached.
Following emergency surgery she was very fortunate to recover from her urinary and bowel symptoms, although she was left with significant neuropathic pain and saddle numbness.
In this case, expert evidence from a consultant in emergency medicine was that the questioning and examination carried out by the ENP was inadequate. Had these investigations been undertaken to an acceptable standard, then the patient’s urinary frequency and altered sensation would have been revealed, as would her altered saddle sensation. This would have led to CES being high on the list of differential diagnoses and an MRI scan would have been ordered as an emergency, leading to a prompt diagnosis and decompressive surgery.
The case was atypical in that it is unusual for patients to recover significantly from a loss of urinary or bowel function once the nerves have been damaged, and this is reflected in the need for emergency surgery in many cases.
There are at least two categories of CES, which are categorised according to the patient’s ability to pass urine. If a patient has altered urinary function but retains some ability to pass urine, they are considered to be in CES Incomplete (CESI). If they have lost the ability to pass urine they are considered to be in CES Retention (CESR). It is universally accepted that a patient in CESI (as the client was on first presentation) should be operated on as an emergency in order to prevent further damage to nerve cells and further clinical deterioration. There is however some dispute among experts as to the timing of surgery once a patient has gone into CESR. Some studies show that once a patient is in CESR, the chances of recovery of urinary function are slim and therefore, for instance, if a patient presents late at night, it is justifiable to delay surgery until the point when a theatre can be fully staffed, rather than carry out the surgery under emergency conditions.
Despite the improvement in urinary and bowel symptoms, the patient was still left with significant and distressing injuries. Following investigation and supportive expert evidence, we submitted a letter of claim with an early offer in order to apply pressure to the defendant to enter into negotiations. A settlement was reached at an early stage.