Case Study F
This case was defended and went to trial. Find out what happened below.
F suffered Cauda Equina Syndrome following a failure to examine her, note her deteriorating condition and accurately report these findings to a consultant. This led to a delay in discectomy surgery. F’s case proceeded to trial after the Defendant Trust denied she even had Cauda Equina Syndrome.
Background
F had a long history of back problems, suffering a disc prolapse in 1995. Back pain troubled her from time to time, but did not significantly impact on her work or social life.
In March-April 2010, F’s back pain became worse and she consulted her GP. On 24th July 2010, she suffered a sudden increase in back pain whilst at work. On 27th July 2010, her GP referred her to the Defendant’s hospital where she was admitted.
On 28th July 2010 F underwent an MRI scan which was interpreted as showing a large L4/L5 posterior disc herniation with inferior migration causing compression of the right L5 nerve route. The radiology report stated
“no cauda equina compression” and F was discharged home.
F went back to her GP for review twice in August 2010. The GP advised her to return to A&E due to increasing neurological symptoms, including a strange feeling in her right buttocks. She also had an episode of faecal incontinence.
F was admitted to hospital late in the evening of 11th August 2010, after being seen by an A&E senior house officer (SHO), who requested the orthopaedic assessment. On 12 August 2010 at 04:00 there was a further SHO review. A rectal examination was performed, which showed reduced anal tone. There was loss of sensation over the right S3/4 dermatome. A neurological examination showed right hip, leg, and knee and ankle weakness. There was reduced sensation at the L3 sensory level.
A further MRI scan was undertaken at 10.36 that morning and reported “no cauda equina compression” again. F was seen on the ward round by an acute medical consultant and an urgent senior orthopaedic review was requested. That review was subsequently undertaken by an orthopaedic surgical registrar, who reported back to the consultant orthopaedic surgeon.
On Friday 13 August 2010 F was seen again on the ward round by the acute medical consultant and reduced right foot movement was noted as a new symptom and struggling to empty bladder was also recorded. The consultant orthopaedic surgeon was requested to assess the patient himself.
F remained in the hospital and underwent a right L5 right nerve root block on 16th August 2010 and on 18th August 2010, F was discharged home after being seen by the orthopaedic consultant.
On 30th August 2010, F suffered a fall at home and was taken to hospital by ambulance in the early hours of 31st August 2010. Another MRI was undertaken and F remained in hospital. Finally on 6th September, 2010 F was reviewed by a spinal surgeon (who had also treated her in 1995). He recorded acute right leg radicular pain, right perineal numbness, bilateral sciatica and right leg sensory loss. After examining F he arranged a L4/5 discectomy procedure that evening. F was discharged home on 13th September 2010.
Outcome
F was left with bladder incontinence and has to perform intermittent self-catheterisation. She suffered from bowel dysfunction and required an anal irrigation system to empty her bowel each day. She was left with sexual dysfunction, severely restricted mobility, with weakness and pain in the right leg and foot and muscle spasms in her thigh, calf and foot. She used crutches to mobilise in her flat and a wheelchair for outside the home. She had upper limb pain due to her reliance on crutches. She had permanent severe back pain and severe-moderate depression. She has headaches as a result of her medication. A spinal cord stimulator was fitted in 2016 to help reduce her pain. F has little prospect of returning to the labour market and requires life-long professional care.
F brought a claim against the Defendant Trust in negligence on the basis that when she attended hospital in July and August 2010, she was suffering from Cauda Equina Syndrome which went undiagnosed. Her case was that she should have been offered emergency decompression surgery on 12th or 13th August 2010 based on the MRI scans and her presenting “red flag” symptoms.
However, liability was denied. The Defendant’s position was that the MRI scans were reported correctly, excluded Cauda Equina Syndrome and the management of F had been appropriate.
The Defendant denied causation, arguing that F did not in fact have Cauda Equina Syndrome and that her condition was caused by Functional Neurological Symptom Disorder (FNSD).
With liability in dispute, the case proceeded to a 3 week trial in the High Court Leicester District Registry.
Judgment
The Judge held that there was a breach of duty by the orthopaedic registrar in failing to:
Undertake a thorough examination of F on 13th August 2010
Correctly note the previously reported bladder and bowel symptoms and reduced anal tone and numbness.
Accurately report F’s presentation and history to the consultant orthopaedic surgeon.
The Judge held that if it was not for these breaches of duty, F would have undergone decompression surgery on 13th August 2010.
Causation
There was a dispute between the radiologists as to whether the MRI scan showed unilateral compression of the nerve roots of the cauda equina (i.e. right S2 to S5). The Judge accepted that unilateral involvement of the cauda equina nerve roots was capable of causing Cauda Equina Syndrome.
The Judge also accepted the evidence of the Claimant’s neurosurgeon that a prolapsed disc can give rise to an inflammatory response, which can cause symptoms such as those reported by F, but the changes would not necessarily be seen on an MRI scan. the Judge accepted that direct compression of the cauda equina nerve roots (S2 to S4) by a prolapsed disc is not always seen on an MRI scan for the patient to have Cauda Equina Syndrome.
The Judge held that on the balance of probability F was suffering with Cauda Equina Syndrome in August 2010 and on the balance of probabilities F’s bladder and bowel problems had been caused by Cauda Equina Syndrome.
Due to the long standing back condition, the Judge was not satisfied that F had proven the delay in surgery had caused her disabilities beyond the bowel, bladder and sexual dysfunction.
The Judge accepted care in respect of her bladder and bowel incontinence were qualitatively different from the care she required in respect of her orthopaedic condition. The Judge awarded F the cost of a live-in carer from the age of 70 and disregarded the fact that F would have required such care on account of her orthopaedic conditions alone.
£1,534,489.83 was awarded to F.