The specialist Cauda Equina claims team within the Penningtons Manches Cooper clinical negligence group recently achieved a substantial settlement for a young woman left seriously disabled by failures in her care at Hull Royal Infirmary, leading to a delay in diagnosis of Cauda Equina Syndrome, a condition which requires urgent diagnosis and surgery to avoid permanent neurological dysfunction. The case was handled by partner Philippa Luscombe and associate Emily Hartland.
The background to the claim is that the claimant (referred to as ‘MH’) slipped on some ice, following which she developed low back pain. She suffered significant back pain over the next few weeks but no other signs or symptoms. A few weeks later MH awoke at home and 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 noticed altered/reduced sensation when doing so. All of these symptoms are signs of potential Cauda Equina Syndrome (caused by a disc in the spine pressing on sensitive nerves and requiring urgent surgery to remove the compression).
Later that day she suffered an episode of urinary incontinence, following which she contacted the local 111 service for advice. She reported that she was experiencing a significant loss of sensation, notable lower back pain and the single incident of incontinence. She was advised by the NHS 111 team that given her reports of numbness in the saddle area and loss of urinary control, she needed to attend her local A&E department as soon as possible. After she had finished work, she went straight to the A&E department at Hull Royal Infirmary. She was triaged and the notes recorded the symptoms that she had developed that day, including the episode of incontinence. MH was triaged as a non-urgent patient and had to wait some time to see a doctor - during this waiting period she was able to control and pass urine but with altered sensation. The ED doctor noted her history and carried out an examination, from which he noted various neurological abnormalities including reduced sensation in her lower limbs and when passing urine, incontinence of urine, reduced ankle reflexes and reduced anal tone. All of these symptoms would be consistent with a potential diagnosis of Cauda Equina Syndrome.
The ED doctor correctly recorded a plan for spinal MRI and neurosurgical advice but there was then a very substantial delay in arranging an MRI scan (which was needed to confirm or exclude a diagnosis of Cauda Equina Syndrome). This did not take place until over 24 hours after MH’s initial attendance at the A&E department. Once the scan was performed it confirmed the presence of a large central disc prolapse compressing the Cauda Equina nerves and arrangements were made for MH to be transferred to a neurosurgical team for surgery.
Since these events, MH has been left with a number of significant ongoing problems as a result of her Cauda Equina Syndrome. Whilst 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 as well as episodes of constipation. She suffers from significant pain and altered sensation in both legs together with neurological weakness in the right leg. Additionally, she developed depression and has been unable to return to work as yet. She requires care and assistance with most activities of day to day living. It is unlikely that there will be much improvement from her current condition and she has a very restricted quality of life as a result.
The Penningtons Manches Cooper team investigated the case and concluded that there were several breaches of duty on the part of Hull Royal Infirmary in the management of the claimant following her attendance. A case was presented on the basis that whilst it is appreciated that many patients attend emergency departments with mechanical low back pain and unilateral sciatica, the vast majority of these do not have features suggestive of possible Cauda Equina Syndrome. However, there will be a small number of patients who present with symptoms which are indicative of the need to consider Cauda Equina Syndrome in detail. Any competent medical practitioner considering the possibility of Cauda Equina Syndrome should know that this is a condition that requires urgent diagnosis and treatment to limit long-term neurological compromise. It is the responsibility of the emergency department clinician to identify those patients at risk of Cauda Equina Syndrome and arrange appropriate and timely subsequent management.
In this case MH presented at the emergency department at Hull Royal Infirmary with a history of increasing back pain, and recent onset of saddle anaesthesia and bilateral pins and needles, one episode of urinary incontinence with a lack of sensation and bilateral radicular pain down both legs. She had contacted the NHS 111 service which had correctly identified that she may need urgent medical review and had specifically advised her to go to the emergency department because of the nature of her presentation. Despite the presentation at triage of features which should have raised concerns of possible neurological compromise or Cauda Equina Syndrome, the triage nurse wrongly allocated MH a triage category of green and it was some three and a half hours before she was reviewed by a doctor. It appears that the ED doctor did recognise the possibility of cord compression and identified the need for an MRI scan but following discussion with the neurosurgical team this was not progressed with any urgency. There were then a number of further breaches over the course of the following day.
It was MH’s case that there was significant unacceptable delay in the investigation and diagnosis of a patient who was presenting from the outset with red flag signs of Cauda Equina Syndrome. With appropriate care she should have undergone surgery approximately 24 hours earlier than she in fact did and there was therefore a negligent delay of approximately 24 hours before surgery was performed. Surgery should have commenced within about 15 hours after the onset of CESI (Incomplete Cauda Equina Syndrome) symptoms whereas in the event it did not take place until almost 39 hours after the onset of symptoms. There was therefore a substantial delay in diagnosing and then treating a patient who presented relatively quickly after onset.
In terms of outcome, whilst it is appreciated that the episode of incontinence would indicate the presence of CESR (Cauda Equina Syndrome with Retention), the expert evidence presented by the team was that early surgery would have made a material difference to the claimant's outcome. There were numerous references in the medical records as detailed above to the fact that MH retained the ability to control the passage of urine until 24 hours after her initial admission. Over time her symptoms of pain diminished and the numbness and anaesthesia which she was suffering in her saddle area and bilaterally in the lower limbs increased. All of these point towards the fact that neurological compromise was continuing over this period and her condition was deteriorating. It is well recognised that neurological deterioration of this type is continuous and it was MH’s case that this was progressing over the period of her attendance at the hospital. In terms of causation, therefore, MH’s case was that while she accepted that on the balance of probabilities with timely surgery she would still not have made a full recovery and would have been likely to have had some ongoing permanent effects, her outcome was made significantly worse as a result of the additional delay of some 24 hours (particularly given her relatively early and quick presentation). In particular it was her case that her bowel, bladder and sexual dysfunction would all have been avoided with timely surgery and that her lower limb issues and compromised mobility would have been significantly better, as would her lower limb pain. It was accepted that her back pain would have been much the same.
Full details of the claim were presented to the trust and NHS Resolution, which instructed solicitors. Initially, Penningtons Manches Cooper received admissions of negligent failings in MH’s care and a delay. Later, there were further admissions that this had had a significant impact on her outcome. Given the admissions made, the parties were then able to work collaboratively to each fully investigate and assess the value of the claim, exchange evidence and proceed to a settlement meeting, the outcome of which was an agreed substantial settlement for the claimant.
Philippa Luscombe, head of the Cauda Equina team who ran the case, comments: “This was an extremely sad case where a young woman has been left with a range of difficulties and disabilities and a very reduced quality of life because of a number of failings in her care. She presented to her local hospital with clear red flag signs of Cauda Equina Syndrome and with appropriate care she could and should have had urgent surgery and would have made a far better recovery. It is difficult to understand how she was left for so long given the symptoms that she had and that were documented by those managing her. However, the trust was quick to admit the failings in her care and dealt with this case sensibly and co-operatively and this was much appreciated by our client and ourselves. While she has received a substantial settlement to reflect the fact that she should not have ended up in the situation that she is in, no amount of money can make up for what she has lost and what she suffers day to day - it will instead just go some way to making life easier for her.”