Patient wins claim against GP for long-term neurological damage after failure to suspect the development of Cauda Equina Syndrome

Posted: 21/02/2018

Penningtons Manches’ specialist Cauda Equina claims team recently settled a case for a man in his 30s who was left with long-term damage from developing Cauda Equina Syndrome. This was compounded by failures on the part of a GP at his local practice.

The firm’s client had a previous history of back problems including sciatica. Such symptoms indicate disc degeneration in the spine, putting an individual at risk of a slipped disc, which can compress the sensitive Cauda Equina nerves at the base of the spine controlling bladder, bowel and sexual function and sensation.

In early 2013 the client injured his back while lifting something heavy at work. Over the rest of that year he suffered from back pain and some sciatic pain in his left leg. In January 2014, his pain escalated significantly and he made several attendances at his GP practice, where he was recommended pain relief and physiotherapy. At this stage, his symptoms were severe but limited to back and left leg pain.

A few weeks later the client had an appointment with the defendant GP in this case. He reported and the GP documented that he now had pain and altered sensation in both legs and a new symptom of perineal numbness. The GP examined him and found numbness in the left side of his anal area. Numbness or altered sensation in this area in the presence of back pain is a red flag symptom for the possibility of Cauda Equina compression.

Despite having noted and recorded this red flag symptom, the GP did not appear to consider Cauda Equina Syndrome or take appropriate action in terms of referring the client straight to A&E or an orthopaedic / neurosurgical team. The GP did subsequently chase up an already ordered MRI scan but did not raise with the orthopaedic team the new symptoms that the client had developed or request urgent action.

A few days later, the client had his MRI scan. The radiologist immediately identified compression of the Cauda Equina nerves and took steps to ensure that he was admitted to hospital immediately. He underwent decompression surgery the next morning.

Following the surgery, the client was left with sensory disturbance in his perianal area and legs, as well as bladder and bowel functional problems. He was told about Cauda Equina Syndrome and red flag signs during his stay in hospital and therefore had concerns that he should have been referred to hospital by his GP practice at an earlier stage. He instructed Penningtons Manches to investigate whether the care he had received was appropriate.

Having taken information from the client and reviewed his records, Penningtons Manches’ Cauda Equina claims team was of the view that the GP did not appear to have considered the possibility of Cauda Equina Syndrome and should have done. The team instructed a GP expert who confirmed that the GP care provided on that day fell below an acceptable standard and amounted to a breach of duty of care. Input was then sought from a spinal surgeon who was of the view that the delay in investigation and diagnosis had adversely affected the client’s outcome.

A case was presented on the basis that the GP’s clinical records entry clearly documented symptoms and signs of Cauda Equina Syndrome which were present in conjunction with back pain. As soon as perianal numbness was found on the GP’s own examination, this mandated a referral to hospital. The client also demonstrated bilateral leg symptoms at this stage – he was now reporting symptoms in his right leg in addition to those present in his left leg. Perianal numbness and bilateral leg pain are both red flags for CES.

The symptoms and signs documented required emergency (same-day) MRI scanning. No responsible body of general practitioners would support the GP’s failure to refer the client to hospital for MRI scanning to confirm or exclude the diagnosis of CES, given these symptoms. It was not acceptable for the GP just to chase the routine MRI scan request that had already been made.

It was alleged that, but for the breach of duty by the GP, the client would have been referred to hospital that day, either directly to an orthopaedic/spinal team or via A&E as a patient with suspected CES. The same-day MRI scan would have confirmed the presence of Cauda Equina compression, an urgent referral to a neurosurgeon or orthopaedic spinal surgeon would have been made and the client would have been transferred to a neurosurgical unit. He would then have had emergency decompression surgery within, at most, 24 hours of attendance at A&E.

The alleged breach of duty resulted in a seven to eight day delay in diagnosis and in the client undergoing urgent decompression surgery to prevent further damage to the Cauda Equina nerves. The evidence from the expert spinal surgeon was that the client’s bladder and bowel functional problems were as a result of the delay in diagnosis. On the balance of probabilities, had he been referred to hospital appropriately, he would have undergone surgery within, at most, 36 hours of the onset of his condition and this would have resulted in a better outcome in terms of his bladder and bowel function, which would have been normal although he might possibly have had some impaired sensation. It was also alleged that the delay contributed to his right leg sensory deficit and sexual function impairment.

The claim was presented to the defendant GP on that basis and, after a short negotiation, the case settled in the client’s favour.

Philippa Luscombe, head of the Cauda Equina specialist team at Penningtons Manches, comments: “Both anal numbness / altered sensation and neurological symptoms in the legs are indicators of possible Cauda Equina Syndrome in a patient with back pain. It is a surgical emergency because after a relatively short period of compression of these nerves, permanent damage will be caused. This GP should have realised that our client might have Cauda Equina Syndrome and referred him straight to hospital. Had the GP done so, our client would have had a much better outcome. 

“While early settlement of the case has been helpful, no sum of money can compensate our client for the lifelong difficulties he now has which have a substantial impact on his day to day life.”

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