Pennningtons Manches Cooper obtains admission of liability for young woman left disabled after a delay in diagnosis of Cauda Equina Syndrome

Posted: 04/06/2018

The specialist Cauda Equina Syndrome claims team at Penningtons Manches Cooper has secured a full admission of liability in a clinical negligence claim brought against Hull Royal Infirmary for a negligent delay in diagnosing a claimant’s Cauda Equina Syndrome and arranging urgent surgery.

Cauda Equina Syndrome is a relatively rare but very serious condition where a prolapsing spinal disc compresses a set of nerves known as the ‘Cauda Equina’ at the base of the spinal cord. These are sensitive nerves controlling, amongst other things, bladder, bowel and sexual function and sensation. Prolonged compression will cause permanent neurological damage and so clinicians need to be aware of the signs of Cauda Equina Syndrome. When it is suspected, it needs to be investigated as a priority and, if confirmed radiologically, urgent decompressive surgery is needed.

The claimant, N, slipped on some ice in early February 2015. Over the next few weeks she suffered quite significant back pain and attended both her GP and A&E at Hull Royal Infirmary. At this stage there were no signs of neurological compromise and she was correctly managed – including being given advice on being alert to signs of concern.

At approximately 11am on 27 March 2015 N awoke at home. She was immediately aware of altered sensation from the waist downwards, specifically around her groin and buttocks, and also the development of pins and needles in both legs. She was able to pass urine but had altered/reduced sensation when doing so. At approximately 15:00 N felt the need to pass urine and went to the toilet. However she found she had lost control of her bladder and passed urine without sensation. She was sufficiently concerned to call the NHS 111 service as she was aware from her previous ED attendance that she needed to seek medical advice if she had issues with bladder function. She was advised by the NHS 111 team that she needed to attend her local A&E department as soon as possible. After she had finished work, at around 9pm, she went straight to the A&E department at Hull Royal Infirmary.

She was triaged at 9.19pm and the triage note reads as follows: ‘Ongoing back problem, had X-ray done on Monday night, NAD, pt states pain has become worse, also has numbness to lt leg and buttock, pt also states has been incontinent today.’ Whilst waiting to see the ED doctor, N was able to control and pass urine but with a lack of sensation. It was then some 3 ½ hours before she was reviewed by a doctor in A&E. His notes include the following ‘Fell landing on buttocks...back pain since. Been seeing osteopath with no improvement. Since this am ↑ pain in back. Pins and needles in buttocks and down both legs (one leg then the other) incontinent of urine multiple times today – not aware that she was passing urine. Tried to PU earlier – poor stream. Taken naproxen with no relief. Seen in ED on Monday – XR lumbar spine and sacroiliac joint. When passing urine → has feeling she needs to empty her bladder but cannot feel the stream of urine. No faecal incontinence. BNO day before yesterday → N. Pain down both legs to the calf, more on the right. Constant dull ache. Shooting. Muscle cramps.’ The doctor carried out a neurological assessment which identified several abnormalities including reduction in anal tone and sensation – an indicator of Cauda Equina Syndrome. The notes concluded ‘Plan d/w radiology reference MRI. Advised discuss with neurosurgical SPR then if agreed for discussion with d/w neurosurgical SPR – would like MRI before seeing the patient. d/w neurosurgical SPR does not sound like neurosurgical problem does not require MRI tonight. Plan: bedrest, bladder scan, catheter – patient not keen. Admit under medics for MRI tomorrow.’

N stayed in hospital throughout the next day. She was reviewed at lunchtime and late afternoon and on both occasions signs and symptoms consistent with Cauda Equina were noted. Still no MRI was arranged. It was not until 6.15pm that second day that arrangements for an MRI scan were instigated. The scan results, which confirmed the presence of Cauda Equina compression, were reviewed at 10.30pm. It was at approximately the same time that N found that having been able to pass urine during the day, albeit with difficulty, she was no longer able to pass urine at all. Arrangements were made for urgent surgery and she was transferred to theatre at approximately 1.00am on 29 March 2015.

Since these events, N has been left with a number of significant ongoing problems as a result of her Cauda Equina Syndrome. While she is able to pass urine, she has no sensation and is unable to tell when she has emptied her bladder. She has to self-catheterise and suffers significant difficulties managing her bladder day to day. Her bowel function is compromised to some degree with episodes of urgency and occasional incontinence and also episodes of constipation. She suffers from significant pain and altered sensation in both legs together with neurological weakness in the right leg.

On learning of the events, Penningtons Manches Cooper felt that the hospital had failed to act appropriately and that there was a case to be investigated. Expert evidence was obtained on breach of duty (negligence) and causation (effect of negligence) and a letter of claim was submitted alleging:

• there was an unacceptable failure on the part of the triage nurse to recognise the potential significance of N’s symptoms - she should have categorised her as needing urgent review – and there was an unacceptable delay in N being reviewed by a doctor;
• the history given by N and the findings of the doctor on examination were signs of Cauda Equina Syndrome. No responsible body of emergency medicine clinicians would fail to recognise that these are red flags symptoms and to consider the possibility of Cauda Equina Syndrome within the differential diagnosis;
• there was a failure at the point of the discussion between the A&E doctor and the neurosurgical registrar to recognise that this was a patient with classic red flag symptoms and presentation of Cauda Equina Syndrome where exclusion or confirmation of the diagnosis was required as a matter of immediate urgency. The failure to arrange an MRI scan and neurosurgical review that night fell below an acceptable standard of care;
• there was an unacceptable delay in further medical assessment and review of N after admission;
• the assessments the following day failed to appreciate the likelihood of Cauda Equina Syndrome and there was an unacceptable delay in arranging an MRI scan. 

It was N’s case that with appropriate care she should have undergone surgery approximately 24 hours earlier than she in fact did. With timely surgery, she would have avoided most of the problems that she now has in terms of bladder, bowel and sexual dysfunction and some of the issues that she now has with mobility.

The trust instructed solicitors who investigated the claim and have now made full admissions that the care N received fell below an acceptable standard.

Philippa Luscombe, partner in the clinical negligence team at Penningtons Manches Cooper, who represented N, comments: “This is a sad case where N presented at A&E with classic signs of Cauda Equina Syndrome and as a result of earlier warnings by NHS 111 that she needed urgent review. Despite this background, there was a complete failure to recognise her condition and act appropriately. She attended at an early stage and had a good prospect of successful surgery and recovery with appropriate action. Instead she has been left significantly disabled at a young age.

“We appreciate that the trust has been open in its admissions of failings and hope that we can now make progress in securing some funds for N to cover further rehabilitation and support and ensure some financial security while she remains unable to work.”

Penningtons Manches Cooper’s specialist Cauda Equina Syndrome claims team can be contacted on freephone 0800 328 9545 or by email at clinnegspecialist@penningtonslaw.com.

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