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Specialist Cauda Equina team settles substantial compensation claim against St Peter’s Hospital, Chertsey for delayed diagnosis

Posted: 29/08/2019

The Cauda Equina claims team at Penningtons Manches Cooper has settled a substantial claim against St Peter’s Hospital, Chertsey in respect of a number of alleged failures on the part of its orthopaedic team in the care of a patient referred by its A&E team with clear red flag indicators of developing Cauda Equina Syndrome (CES).

The claimant was in his late 40s and had a long history of back problems. At the time of the events in 2014 he suffered a significant escalation of his back pain. He attended his GP and A&E at St Peter’s, Chertsey on several occasions. In the early stages he had no signs of neurological dysfunction and was properly assessed in this regard.  However, he gradually began to develop neurological symptoms. He initially had some numbness in his right foot and leg which spread to his “saddle” area – a red flag for potential CES. He also started to have difficulty passing urine – a further ‘red flag’ sign.

On the morning of 26 February 2014, concerned by his increasing pain, numbness in buttocks and difficulty passing urine, the claimant returned to St Peter’s A&E Department. He thought that the initial assessment by the A&E doctor was inadequate but it does appear that, despite this, an MRI was arranged by the A&E clinician. An MRI is the investigation required when Cauda Equina is suspected. The MRI scan was performed and the results reported later that day confirmed that the claimant had clinical signs of CES.

The A&E clinician correctly contacted the hospital’s orthopaedic team. Despite the clinical presentation and findings on MRI, no-one from the orthopaedic team came to see the claimant and no steps were taken to either list him for surgery under the orthopaedic team as a matter of urgency or transfer him to another hospital with an available neurosurgical team and facilities. Instead the claimant was simply discharged home. 

He was called back in the following morning by one of the orthopaedic consultants but despite the claimant’s presentation and the imaging and the fact it was over 24 hours since he first attended the hospital with signs of CES, the consultant took no steps to arrange urgent surgery. He simply suggested that arrangements should be made to admit him for surgery a few days later.  

It was only the review of a junior orthopaedic doctor later that afternoon that prompted referral to a neurosurgical team. Things then started to progress and he was transferred to a neurosurgical team late that night, with surgery the following day. By the time he had surgery, it was well over 48 hours since his first presentation at the A&E department. 

Although the claimant subsequently made a good recovery - with no ongoing bladder or back symptoms - he was left with other neurological complications of CES that affect all aspects of his day-to-day life. These include bowel and sexual dysfunction, fatigue, and altered balance and mobility. He has been unable to participate in childcare and household activities as he had always done; his leisure and social activities have been significantly curtailed; and he had to cease commuting to work and have his job adapted such that he could work at home full time. Understandably this has had a significant psychological effect upon him and he is aware that all of these issues are likely to remain long term.

The claimant was concerned from his subsequent research into CES that he had classic signs of CES and was an urgent case but was not treated appropriately. He instructed Penningtons Manches Cooper to investigate a claim on his behalf. The team obtained supportive expert evidence from an A&E consultant, an orthopaedic/trauma consultant and neurosurgeon. Based on their evidence, a claim was presented to the hospital alleging that:

  • Prior to and/or following the MRI scan there should have been a careful review of the claimant’s history, in particular the nature of his urinary dysfunction, an examination to assess sensation in the perineal area, and a digital rectal examination to assess anal tone. 
  • The defendant failed to carry these out and to appreciate that perineal/sacral sensation and/or anal tone was diminished.
  • Following the MRI scan, the orthopaedic surgeons, either by themselves and/or through the failure of the A&E Department, failed to appreciate that, despite the following evidence, the claimant was suffering from incomplete Cauda Equina Syndrome (CESI) which required immediate neurosurgical and/or spinal surgical review:
    • severe back/leg pain and numbness spreading to the buttocks
    • progressive right sided motor weakness
    • urinary dysfunction
    • MRI scan indicating compromise, by a large disc fragment, of the spinal canal and specifically the Cauda Equina
    • altered perineal sensation.
  • Through its A&E Department and/or orthopaedic surgeons, the defendant also failed to:
    • clinically review the claimant after the MRI scan despite this confirming radiologically the presence of Cauda Equina compression
    • review and/or appreciate the significance of the radiology given the clinical signs which were also indicative of incomplete CES
    • consider and/or diagnose CESI
    • arrange for a neurosurgical review with a view to transfer
    • take any steps to arrange for the claimant to be considered for urgent decompressive surgery
    • and wrongly discharged the claimant home.

The claimant’s case was that, at around 1700 hours on 26 February 2014, the day of his admission, the orthopaedic team should have had/been given sufficient information to identify that this was a patient with likely CESI given his clinical presentation and radiology findings which confirmed compression of the Cauda Equina - and thus a surgical emergency - and arranged to clinically review him. At that stage, a spinal surgeon and/or neurosurgeon should also have been contacted and asked to urgently review the claimant.

Following such a review, including that of the MRI scan, a formal diagnosis of CESI should have been reached and arrangements put in place for transfer of the claimant (if needed) and immediate surgical decompression.

It was alleged that, had such surgery taken place, or at any point in time up until around midday on 27 February 2014, the claimant would have been left with a significantly better outcome. Specifically, it was alleged that the claimant has sustained permanent damage to the S1 nerve and now suffers from significant bowel and sexual dysfunction; cramping and pain in the right thigh; pain and sensory disturbance in the right leg; imbalance; fatigue; and consequential low mood sufficient to qualify for a diagnosis of major depression.

The case was contested in all respects from the outset. The hospital denied any failings on the part of its staff and argued that, even if there was a delay, it had made no difference to the claimant’s outcome. Given the dispute, we had to issue court proceedings and run the case all the way through a court timetable towards trial with it being denied at each stage. 

The defendant eventually indicated a willingness to explore settlement and the parties reached a negotiated settlement for a substantial sum after a settlement meeting.

Philippa Luscombe, partner in the clinical negligence team and head of the Cauda Equina claims team, comments: “While we are very pleased with the settlement of this claim and believe it will now provide some security and options for our client, it was very frustrating that the case had to go on so long before the other side eventually agreed to settle.

“We believed from the outset that it was clear that our client should have been identified as suffering from developing CES within a few hours of his arrival at hospital and then recognised as a surgical emergency who needed surgery as soon as possible. However, the trust denied the case throughout and it was only once most of the evidence was complete and the matter heading towards trial that it indicated a wish to settle. 

“This patient had classic red flag signs of CES, confirmed on imaging and should have been recognised as needing urgent surgical intervention. It is hoped that lessons will have been learned so that other patients do not end up with the same delays and avoidable consequences.”

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