The clinical negligence team at Penningtons Manches LLP has recently settled a claim for a man left with long-term bladder, bowel and sexual dysfunction after his local A&E department failed to recognise and respond to signs of Cauda Equina Syndrome, a condition where a prolapsed disc in the spine causes progressive damage to a very sensitive group of nerves at the base of the spine. The patient had a history of intermittent back problems which flared up and resulted in several attendances at his GP. Initially he suffered from back pain and right leg pain but this grew steadily worse, resulting in an A&E attendance and increased painkillers.
A few days later, he noticed that his right leg was starting to feel numb and that he was also suffering some numbness in his left leg and around his anal and buttock area. Bilateral leg numbness or weakness and any altered sensation in the genital / anal / buttock area against a background of back pain are red flag signs for the possibility of Cauda Equina compression. While it is a relatively rare condition, it requires emergency surgery to relieve the nerve compression. Otherwise a patient may end up with long-term damage and disability.
The patient called his local out of hours service which correctly recognised these symptoms and advised him to go straight to his local A&E department at Kingston Hospital, which he did. There are no clinical records for this attendance at the hospital (the hospital having lost them) other than a discharge summary confirming a diagnosis of sciatica. The patient had however explained his symptoms which included right hip pain progressing to his lower back and into both legs and numbness in his groin, genitals, buttocks and legs. A full neurological examination was not carried out and no consideration appears to have been given to the possibility of Cauda Equina Syndrome. He was discharged with pain relief.
The condition progressed and three days later the patient suffered an episode of urinary incontinence followed by problems passing urine. The next day he reattended at A&E and this time the likelihood of Cauda Equina Syndrome was noted and actioned. He underwent an MRI scan and was transferred to a neurosurgical team for surgery. He has been left with bladder and bowel dysfunction in the form of both urgency and frequency and sexual dysfunction, all of which it was alleged would have been avoided with appropriate care. His day to day quality of life and activities are significantly affected.
Philippa Luscombe, who leads the Cauda Equina specialist team within Penningtons Manches’ clinical negligence practice, advised the patient that there were good grounds for a claim. Full investigations were carried out and based on expert evidence a claim was submitted to the hospital alleging that on his first attendance staff had failed to advise him of the red flag signs of Cauda Equina Syndrome and to return to hospital immediately if he experienced any of these symptoms. During his second attendance, they had failed to act upon his symptoms of Cauda Equina Syndrome, in particular numbness around the anus / buttocks and in both legs, to record any adequate history of his complaint and developing condition, to carry out a detailed neurological examination, to order an MRI scan of his spine and to refer him to the orthopaedic team and / or the neurosurgeons. Rather than considering and acting upon the possibility of Cauda Equina Syndrome, they had discharged the claimant with a misdiagnosis of sciatica.
It was alleged that with proper care he would have undergone an MRI scan and surgery at a stage where it would have been early enough for him to have retained normal or near normal bladder and bowel function and that the negligent delay resulted in permanent neurological damage. Initially the trust denied any negligence (despite not having records for the patient) and so court proceedings were issued and served. The trust then made a full admission and the parties entered negotiations, resulting in a substantial settlement for the claimant.
Philippa Luscombe comments: “We deal with a high number of cases involving a missed and / or delayed diagnosis of Cauda Equina Syndrome and the pattern is usually the same. The focus is on the claimant’s back pain, which is often very severe, and insufficient heed is taken of symptoms reported by the claimant which indicate neurological issues. All GP and A&E practitioners should be aware of the red flag symptoms for Cauda Equina Syndrome and respond to them by appropriate questioning and neurological examination as the consequences of a delay in diagnosis can be devastating. Ultimately the trust admitted its failings but it was frustrating that we had to incur the cost of issuing and serving court proceedings to obtain that admission. More education is clearly needed about this rare but very significant condition.”