The Penningtons Manches clinical negligence team has recently agreed the settlement of a claim against St Mary’s Hospital, Isle of Wight, for the alleged failure to appropriately advise a client of the “red flag” symptoms of Cauda Equina Syndrome (CES) when she was discharged from A&E in July 2012. This caused a delay in diagnosis and decompression surgery to treat her condition.
In or around May 2012, she developed an onset of significant lower back pain for the first time. Initially, her symptoms were of back pain which continued to increase in severity. She attended her GP surgery and St Mary’s Hospital on a number of occasions expressing her concerns about her increasing back pain. Each time she was advised that she was suffering with “common back pain” and there was little that could be done to help her. She was advised to take painkillers and that, eventually, her symptoms would settle.
However, her symptoms continued to progress over the subsequent weeks and she began to develop left-sided sciatica. By the latter part of July 2012, she had developed bilateral leg pain and numbness. Understandably, the client was very concerned about the evolving nature of her symptoms and, after a brief telephone discussion with NHS 111, she was advised to attend her local A&E department as a matter of urgency.
Upon attending A&E, she was seen relatively promptly by a doctor to whom she reported the severe lower back pain that she had been experiencing since May 2012, and that she had developed an onset of bilateral leg symptoms in the last few hours. It was evident from the medical records that the clinician did consider the possibility of CES due to the nature of the examinations performed.
However, it appears that the doctor did not consider that her condition required any further investigation at A&E or that she required urgent treatment. She was discharged with a recommendation that she needed an MRI scan which her GP needed to arrange for her. The client was further advised on her discharge that, if she was to “wet herself” (incontinence), she should return to A&E. Other than being advised to return if she developed incontinence, no further advice was provided about the other symptoms of impending CES or what to do should they arise. She was provided with various pain medications in hospital, which made her feel nauseous and unwell.
After her discharge, the client was in extreme pain and, as she was unable to care for herself, she stayed with her parents over the subsequent week. However, her condition deteriorated and she began to suffer with an altered sensation that she was unable to fully empty her bladder. Although she was aware of the advice to attend A&E if she wet herself, as she was having the reverse difficulty, she was not unduly concerned, and attributed these difficulties of emptying her bladder to her pain.
Approximately two days after her discharge, the client then experienced an onset of “numbness in the genital area” together with loss of sensation when passing urine. However, she did not know the significance of these symptoms at the time. Over the subsequent days, she remained in bed in extreme agony with her back and she felt very sick, to the extent that she was unable to eat or keep water down.
The client attended a routine appointment at spinal triage approximately a week later. During this appointment, a history was taken of her evolving symptoms and the clinician appreciated the severity of her condition and arranged an urgent same day MRI scan. The scan findings were reported to be consistent with Cauda Equina Syndrome. She was consequently transferred to the specialist neurosurgical team for decompression surgery. However, by the time she was seen by the specialist team, it was considered that, given the delays in diagnosis, she was likely to be “beyond help”.
Remarkably, the client made some improvement post-surgery but she has been left not only with significant issues with pain and mobility but also with bladder function as, although she experiences the sensation of urgency, she cannot feel the passing of urine and has experienced episodes of incontinence. She also has problems with bowel and sexual function.
Penningtons Manches was instructed to investigate her concerns about the treatment she received, particularly in respect of the advice she was given during her A&E attendance in late July 2012. An independent expert was commissioned who was critical that the only advice given to her on discharge was to return if she developed “urinary incontinence”.
The expert was of the opinion that the treating A&E doctor was clearly considering the possibility of CES and, if he was happy that this possibility had been ruled out on the day, then any reasonably competent A&E clinician would have ensured that the client was made aware on discharge of the “red flag” symptoms and, should they develop, to return to A&E urgently. These symptoms comprised:
The expert said that these are obligatory for safety netting and that any reasonably competent doctor would advise the patient to come right back to A&E if any (ie one or more) of these symptoms were to develop. Had the client been appropriately informed upon her discharge, she would have re-attended A&E at an earlier stage and would have undergone decompression surgery before her symptoms deteriorated further.
Naomi Holland, a lawyer in the Penningtons Manches clinical negligence team who ran the case to conclusion, comments: “Cauda Equina Syndrome is widely regarded among medical professionals to be a very severe condition which should be investigated and treated with utmost urgency. CES is a progressive condition and, therefore, if a patient’s symptoms give a doctor concerns about the possibility of CES - even if it is ruled out upon initial presentation - it is vital that the patient is advised about the risk of developing certain symptoms and what to do if they arise.
“Sadly, in this case, our client was not appropriately informed and she was unaware of the significance of her deteriorating condition. As a consequence, she was unable to take matters into her own hands and seek further advice when she needed to. This case highlights the significant impact that delayed diagnosis of Cauda Equina Syndrome can have on a patient and our client wishes to highlight these issues in the hope that future occurrences can be avoided."
For information on Cauda Equina Syndrome, click here.