Penningtons Manches has recently settled a case for delayed diagnosis of Cauda Equina Syndrome against Hampshire Hospitals NHS Foundation Trust.
The firm’s client, a new mother, presented to 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 examined by an emergency nurse practitioner who carried out a cursory interview and examination, diagnosing 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.
Patients frequently attend A&E with back pain and sciatica. There are a variety of causes, and patients depend on the skill and competence of A&E practitioners to distinguish between the less serious causes that can be managed conservatively and those that require emergency intervention. Cauda Equina Syndrome usually results from a herniation of a lumbar vertebral disc, pressing on the nerve roots which control saddle sensation, urinary function and bowel function. The damage to the nerve roots is often permanent and can lead to devastating long term consequences.
Patients are not always aware of the significance of their signs and symptoms, and in some cases can be embarrassed to discuss certain aspects of their condition, particularly in terms of genital or anal sensation. For these reasons, careful questioning and examination of all patients is essential. In addition, patients should be advised on the “red flag” symptoms that suggest a potentially serious deterioration in their condition.
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.
Philippa Luscombe, a partner in the clinical negligence team at Penningtons Manches, said: “This case demonstrates that some patients can improve following the development of CESR and therefore prompt surgical intervention may well still be of benefit even when a patient presents in CESR. We have access to some leading experts in this field and we are confident that we can present the most up to date and accurate opinions when investigating these cases. Because of the potentially devastating consequences of CES, there are ongoing studies and we look forward to upcoming publications of further evidence.”
Despite the improvement in urinary and bowel symptoms, the patient was still left with significant and distressing injuries. Following investigation and supportive expert evidence, Penningtons Manches 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.