Penningtons Manches settles claim against NHS Trust for multiple failures leading to delayed diagnosis of Cauda Equina Syndrome

Posted: 19/06/2017

The Penningtons Manches clinical negligence team recently settled a substantial claim for damages against North Middlesex Hospital for multiple failures to recognise red flag signs for Cauda Equina Syndrome, resulting in a significant delay in diagnosis and surgery and long term disability for the claimant. Cauda Equina Syndrome is a condition where a prolapsed disc in the spine causes progressive and permanent damage to a very sensitive group of nerves at the base of the spine (the Cauda Equina). It is a relatively rare condition but one that requires emergency surgery to avoid permanent neurological disability, therefore doctors should be alert to any red flag symptoms.

The patient had a past history of low back pain and previous scans had shown some degenerative changes including a lumbar spine disc prolapse, which put him at risk of developing Cauda Equina Syndrome.

In mid-December 2012, the patient’s back pain recurred and he attended his GP practice to request painkillers to manage the pain. At this time, he was suffering significant lower back pain which was radiating down into both buttocks but had no other symptoms. He had no problems with sensation, or bladder / bowel function and this was appropriately checked by his GP.

On 20 December, the patient suffered increasing back pain throughout the day which was not relieved by the painkillers he had been prescribed. He then began to have some difficulty in fully emptying his bladder but at this stage still had full sensation and simply attributed this to being in so much pain in his back when trying to pass water.

During the course of 21 December, he found that the pain in his buttocks was spreading down the back of both legs. He also developed abdominal discomfort and as the day progressed he found that when he was passing notably less urine in one attempt, although he still had control. By the late afternoon / early evening, he became aware of a numb sensation around his genitals and buttocks. 

The patient’s wife decided to carry out some research on the internet and noted advice that symptoms of numbness in the genital area, pain in the back and pain in both legs together with problems passing urine could be an urgent condition. Prompted by this, the patient called the out of hours service and reported his symptoms. The out of hours service recorded a history of back pain, problems passing urine and numbness in the buttocks and groin / genitals and correctly suspected and documented the suspicion of Cauda Equina Syndrome, making clear to the patient the urgent need to attend A&E. 

At 01.08am on 22 December, the patient was triaged at the North Middlesex University Hospital A&E department. It was noted in the triage record that he had sciatica and was having difficulty urinating and complaining of numbness at the back of the thigh, knee, buttocks and groin with difficulty when walking. 

It was almost four hours before the patient underwent medical review and once he was seen by the A&E doctor, he explained the symptoms that he had had been suffering over the last few days including the fact that pain had caused him difficulty in passing urine on the 20^th but that he had developed more significant problems with passing urine on the 21^st and the development of numbness around his buttocks, groin and genital area as well as down both legs. His wife then specifically mentioned her research on the NHS website which had described these symptoms as red flag, prompting her to call the out of hours service which then advised them to attend A&E. 

The doctor carried out an abdominal and rectal examination and made a diagnosis of constipation. He noted only 'tightness of the perianal region' but also that it was 'difficult to pass urine'. The doctor did not carry out any sensory, neurological, power or reflex testing. Having been given a diagnosis of constipation, the A&E team referred the patient on to the surgical team.

After repeating the same history and symptoms to the surgical team, the patient was specifically asked about passing urine. He confirmed that he could pass urine but only in small amounts, and again his wife raised the issue of the NHS website referring to these symptoms as being red flag. As with the A&E doctor, the surgical doctor carried out an abdominal and rectal examination but did not carry out any testing of his lower limbs, although he noted bilateral limb pain.

The patient was advised that the bowel and bladder problems were likely caused by the amount and variety of painkillers he was taking and that he would be given an enema. He was discharged home that morning and remained at home largely confined to bed for the next two days, still without bowel movements. Although he was able to pass urine in a controlled fashion, it was only in small amounts.

By the morning of 25 December the patient was in so much pain that he reattended the A&E department. The triage note referred only to him suffering from constipation despite him reiterating his history of back pain and the development of the symptoms of urinary problems and numbness for which he had attended A&E previously. He was immediately referred to the surgical team without review by an A&E doctor. The surgical notes related entirely to constipation with an abdominal and a rectal examination, the results of which were described as an ‘empty rectum’. A repeated diagnosis of constipation secondary to opiates was given and again following a phosphate enema the patient was discharged.

The  patient’s symptoms continued over the next two days until he saw a spinal surgeon privately on 27 December. Once he had reported his symptoms, an urgent MRI scan was arranged and Cauda Equina compression was confirmed. He underwent surgery to decompress the nerves on 28 December.

Since these events the patient has been left with no sensation in his urinary tract, no sexual sensation or function, disrupted bowel function and motor and sensory disruption in his lower limbs. He has suffered depressive symptoms and fatigue. All aspects of his life have been significantly affected, including his ability to maintain his work. 

Once the specialist clinical negligence team at Penningtons Manches LLP had investigated this claim and obtained expert evidence, a number of serious failings in the standard of care provided to the patient during his two hospital attendances were identified, including: 

• When he presented to the triage nurse on 22 December, he described several major red flag symptoms of back pain. These included significant and increasing back pain, problems with urinating, bilateral sensory deficit (reported as numbness at the back of his thighs, knees, buttock and groin) and difficulty in walking (decreased motor power). This constellation of symptoms should have prompted an immediate consideration of the possibility of Cauda Equina Syndrome and a high triage category by the triage nurse - to be seen by a doctor within a maximum of one hour. 
• When he was then seen by the examining A&E doctor, the history described was inappropriately brief and omitted several relevant and important details which were both reported by the patient and already available to the doctor by way of documentation from the triage assessment. There is no evidence that the A&E doctor properly questioned the patient in relation to the red flags for back pain and there was a specific failure to document the abnormal sensation reported in the buttocks, genital and groin area and bilateral leg symptoms. There was also a clear failure by the A&E doctor to consider the possibility of Cauda Equina Syndrome.
• Given his presentation, the possibility of Cauda Equina Syndrome as a diagnosis was mandated. There should have been a full examination and assessment of the peripheral nervous system to include power, tone, sensation and / or reflexes of the lower limbs, but none of these examinations were either carried out or recorded. There was no documentation of any perianal sensation testing which should have been carried out. 
• The conclusion that the problem was purely constipation was completely inappropriate. The only acceptable management at this point in time with the range of symptoms reported was to consider Cauda Equina Syndrome as the most likely diagnosis with immediate referral to an orthopaedic team, arrangement of an urgent MRI scan and, should the MRI scan confirm radiologically the diagnosis of Cauda Equina Syndrome, referral on to a neurosurgical team. Both the diagnosis of constipation and the decision to refer the patient to the surgical team represented unacceptable care. The apparent complete failure to question the patient about red flag symptoms, take heed of those symptoms recorded by triage and consider the possibility of Cauda Equina Syndrome were also unacceptable.
• In relation to the surgical doctor, there was again a failure to properly explore all of the symptoms which were reported by the patient and in the triage notes. Although the doctor did document issues in relation to bowel and urine function, he did not explore the issue of the bilateral sensory disruption. The examination carried out by the surgical doctor also fell significantly below an acceptable standard with a complete failure to examine the peripheral nervous system and in particular the perianal sensation. 
• The decision by the surgical doctor that the developing retention of urine was secondary to constipation and to then proceed with management based on this diagnosis before discharging the patient was entirely inappropriate as any description of back pain and urinary problems combined should immediately alert any junior doctor to the potential likelihood of Cauda Equina Syndrome. He should have considered this possibility and made arrangements for the patient to be transferred to the orthopaedic team and undergo an MRI scan. 
• When the patient reattended at A&E on 25 December, although his main focus was on constipation and back pain, he had attended a couple of days previously with reports of bilateral sensory symptoms, saddle anaesthesia and urinary disruption, of which the A&E team should have been aware. There were failures by the triage team to consider the full picture of his presentation, to consider the possibility of Cauda Equina Syndrome, and to arrange urgent review by the A&E team within an hour. 
• In relation to the second assessment by the surgical team on 25 December, at which point the patient was suffering from ongoing urinary problems and back pain together with numbness in his saddle area and bilateral sensory symptoms in his lower limbs, the focus purely on a diagnosis of constipation was entirely inappropriate. The history taken was again inadequate considering the information available to the surgical doctor.  
• The second diagnosis of constipation by the surgical team was inappropriate, not only because the appropriate diagnosis of Cauda Equina Syndrome should have been considered, but because the patient had shown no response to enemas and had an empty rectum, meaning the diagnosis of constipation itself was inappropriate. 
• Had the patient been appropriately assessed at the time of his attendance on 25 December, the suspicion of Cauda Equina Syndrome should have been raised and an urgent MRI scan to investigate should have been arranged, as well as referral to the orthopaedic team and onwards to a neurosurgical team.

It is the patient’s case that Cauda Equina Syndrome should have been suspected from the time he was triaged at 01.08am and appropriately actioned by way of urgent investigation (as advised by the out of hours service). He should have then undergone urgent MRI scanning and orthopaedic review at North Middlesex Hospital within up to two hours of his attendance (allowing time for an A&E review in the first instance) and should then have been referred on to a neurosurgical team. On the balance of probabilities, an MRI scan performed on 22 December would have confirmed the presence of Cauda Equina Syndrome and he would have been transferred to a neurosurgical team. He probably would have undergone surgery on the morning of 22 December, but in any event by the early hours of the afternoon, and therefore within 24 hours of the onset of his Cauda Equina Syndrome symptoms and within 48 hours of the first signs of any urinary symptoms. 

Had appropriate care been provided, it is likely that he would have had full control of his bowel and bladder post surgery with, at worst, some loss of sensation and would have retained his sexual function and he would have avoided the loss of sensation that he has been left with in his genital / groin / buttock area. It is accepted that his leg symptoms and back pain would probably have been similar to the outcome in any event. 

The claim was investigated and presented to the hospital trust, which carried out its own investigations and responded in a timely fashion to admit the failures and damage alleged. A range of expert evidences assessing the nature and impact of the various difficulties that the patient had been left with were obtained and from these a detailed schedule of loss was drafted. Both parties entered and successfully concluded negotiations. 

Philippa Luscombe, partner and head of the Cauda Equina specialist team, comments: “We unfortunately encounter a number of claimants left with significant disability after Cauda Equina Syndrome where they have presented with the known ‘red flag’ signs but appropriate action has not been taken. Timing of surgery in these cases is critical to the outcome and it is so frustrating to see people left with long-term loss of quality of life because clear warning signs of neurological compromise were ignored. This case fits a pattern we have seen in many cases, and to have been through two different departments on two separate occasions and not have one doctor properly assess his presentation meant that this patient was severely let down. Whilst the trust was co-operative in dealing with the case which means that the patient has recovered substantial damages, these will not make up for the significant impact the avoidable nerve damage has had on his life and his future.”

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