One of the areas of clinical negligence claims where we see the same failures over and over again, often with devastating consequences for the patient, is delayed or missed diagnosis of Cauda Equina Syndrome (CES). The Cauda Equina are sensitive nerves found at the base of the spine which affect lower limb power and sensation, bladder, bowel and sexual function / sensation. Prolapsed vertebral discs can press on those nerves and prolonged compression will cause permanent, irreversible damage. The result can be reduced or absent bladder and bowel control.
CES is a relatively rare condition but is known to have some key ‘red flag’ symptoms, so anyone presenting with back pain and signs of neurological compromise in the lower limbs / bladder / bowel should be considered as a possible CES patient and undergo urgent MRI scanning. At its early stages, CES requires emergency surgery to stop permanent damage.
Unfortunately, despite these ‘red flag’ signs, we frequently encounter cases where the significance of patients’ symptoms is not appreciated or acted upon, which then leads to a delayed diagnosis and poor outcome. At its worst, patients end up with very limited mobility, dependent on catheterisation and manual bowel evacuation, unable to work and needing care. Often this means that CES patients cost the NHS and other statutory funding services a considerable amount of money, be that in NHS care, social services support, benefits or otherwise. In addition, because of the serious consequences, many of these patients who have suffered a failure in their care pursue clinical negligence claims. When successful, they are usually substantial value claims – often well into six figure sums.
It surprises us that, given the volume of such claims and the sums involved, the NHS does not focus on the diagnosis and management of care for CES patients, resulting in better outcomes and reduced cost to the NHS. What is really needed is simply clear training and guidance.
However, it looks as though steps are now being taken to try to remedy this. A Government report titled ‘Getting It Right First Time’, published last week, has suggested that up to £27 million could be saved by the NHS if it improves its spinal care provision. The report identified “unacceptable” standards and inefficiencies, noting in particular issues of delayed MRI scan appointments to confirm diagnosis and delayed / cancelled surgical procedures.
The report found that the NHS pays out approximately £100 million each year in successful clinical negligence claims arising out of failures to properly diagnose / manage CES and flagged that the issue is not just financial, but the “potentially life changing impacts on patients”.
Other aspects of spinal care were also considered in the report, which in total makes 22 recommendations for spinal care across the country. Those relevant to CES patients include implementing a system of referring patients without delay to 24 hour MRI scans in all hospitals, and ensuring all major trauma centres have around the clock ability to operate on urgent spinal patients.
Philippa Luscombe, a partner in the Penningtons Manches clinical negligence team and head of the specialist Cauda Equina Syndrome claims team, comments: “In my experience of dealing with these claims, I have over the years seen first-hand the devastating effects that a delay in diagnosis and surgery can have. It has always surprised me that despite the awareness of CES, its ‘red flag’ signs and it being recognised as a condition that requires immediate surgery, it is often not acted upon or treated with the necessary urgency.
“With relatively little cost, the NHS could improve care by way of training and standard guidance, thus reducing the number of people suffering such poor outcomes, and in turn the huge financial burden on the NHS. I am therefore delighted to see that this area of spinal care is finally being looked into. We will watch with interest and hope to see changes being implemented to improve care for CES patients. In the meantime this report should help to raise awareness of the condition and its implications.”