Case Study G

G suffered Cauda Equina Syndrome after the GP failed to arrange transport to hospital and left G taking public transport when her condition was critical.  

Background

G had a history of short episodes of back pain.  On 1 September, G woke up with low back ache, tingling down her right leg and some numbness to the right of her buttock area. G thought this was sciatica, which she had previously suffered.  G took strong painkillers which did not help. 

On 3 September, G noticed that she had difficulty in passing water. She tried to go but struggled.  By 4 September, G found it difficult to walk and could only pass water by squeezing her fist into her stomach.  G was unable to obtain an appointment with her GP for that day. 

On 6 September, G saw Dr X after insisting for an appointment.     Dr X correctly suspected Cauda Equina Syndrome but failed to inform G that he suspected this or that she needed to get to hospital as an emergency. G was given a referral letter to attend hospital.  G had no means of transport nor  money for a taxi to get to hospital (40 minutes drive away). G explained this to Dr X.  Dr X failed to arrange an ambulance.  G had no choice but to walk home. G was unaware that her condition was an emergency. Two days later, G developed bladder and bowel incontinence.  

On 10 September, G attended her GP surgery and saw Dr X again.  Dr X was surprised to see her,  knowing the seriousness of her suspected condition.  Notwithstanding, Dr X simply told G to get to hospital, and again, failed to arrange an ambulance.  G travelled to hospital by bus, in debilitating pain.  

An MRI scan was done as emergency, Cauda Equina Syndrome was diagnosed. Emergency decompression surgery was performed at midnight. 

Outcome

G was left with urinary and bowel incontinence, sexual dysfunction, reduced power in her right leg, neuropathic pain causing electric-shock sensations in her legs, feet and perineum and a  psychiatric illness.

The Defendant contested liability throughout the case.  The Defendant’s case was that Dr X explained that G’s condition was an emergency and there was no failure to ensure G’s immediate attendance at hospital.  Further, Dr X alleged that G was partly to blame for her condition.  G successfully settled her case for a six figure sum.  

Case Study E 

E suffered Cauda Equina Syndrome after a failure to perform an MRI scan which would have indicated a need for decompression surgery.

Background

E had a long history of chronic back pain. For a number of years, she had attended the Defendant’s hospital regularly for investigation and treatment.

In November 2004, E had an MRI scan which confirmed bulging of the discs in her spine at the L4/5 and L5/S1 levels.

In 2006, E started to hobble due to reduced mobility of the right leg and in December 2006, her GP referred her to the orthopaedic department of the Defendant Trust.

On March 9, 2007, E underwent an MRI scan of her lumbar spine, which revealed a moderate size central disc prolapse at L5/S1, both S1 nerve roots were involved, there was a very small central disc prolapse at L4/5 and the discs were reported as degenerate.

E attended her GP in March and April having developed chronic lower back pain, a right leg limp and being unable to sit for long. The GP diagnosed her with sciatica.

On 24 May E fainted following severe back pain. She attended hospital the following day. She was noted to have severe pain, be hobbling and had developed weakness now in her left leg. E was discharged and was
advised that if she had saddle anaesthesia or sphincter disturbance “red flag” symptoms, then she should be reviewed immediately.

In the afternoon of 26 May E developed new symptoms.  She lost sensation around her anus and urethral area and had no sensation whilst passing urine.  An out of hours GP was called at 19.30 and after attending he noted “red alert” for Cauda equine Syndrome.  E was taken by ambulance to hospital.

At 21.52, E arrived in A & E. At 23.15, E was examined and it was noted that she was numb in her upper thigh and bottom but no history of incontinence or retention and no loss of power was recorded. The notes stated she did not have Cauda Equina Syndrome.

E was discharged and advised to see her GP in a couple of days.  She was advised to seek urgent review if she suffered “red flag” symptoms including incontinence of urine or inability to pass urine, faecal incontinence or constipation.

E attended her GP on May 29, complaining of urinary incontinence and intermittent numbness in her groin. Her GP advised her that he would try to expedite her appointment for a nerve root block.

By May 30, E’s symptoms had deteriorated. Her GP carried out a ‘safety net call’ to E and he noted that she was incontinent of urine and was experiencing increased saddle anaesthesia. He referred her as an emergency to the orthopaedic department of the hospital.

On admission to hospital E’s symptoms were noted, including 24 hour incontinence of urine, she had not opened her bowels in 4 days and she had no sensation when flatulent.  The clinical impression was Cauda Equina Syndrome.  E underwent L5/S1 discectomy and decompression surgery that night.

Outcome

E was left doubly incontinent, with weakness in her left leg and foot and ongoing pain in her back.  E had ongoing mobility problems resulting from reduced sensation and weakness in her left leg and foot.  She walked using two crutches.  She experienced cramp in her leg at night which disturbed her sleep.

E had reduced sensation in the perineal area and persistent severe back pain, which required her to regularly alternate between standing and sitting.  E suffered recurrent urinary tract infections requiring prophylactic antibiotics. E had no urethral sensation and had to self catheterise. E had to use an irrigation system to empty her bowels. C suffered from permanent sexual dysfunction. E suffered low self esteem and psychological symptoms that were anticipated to be permanent. E had worked as a fishmonger in a supermarket before her condition and it was not anticipated she would return to work.

E brought a claim against the Trust on the basis that they failed to admit her for an urgent MRI scan on May 26, 2007, and to undertake decompression and urgent discectomy within 24 hours of that admission.

E’s expert evidence was that but for the Trust’s negligence, she would most likely have been in incomplete Cauda Equina  Syndrome (CESI).  Her bladder and bowel would have been normal; sexual function would have been largely normal and the weakness and cramps in her left leg would have gone.  She would not have required crutches to mobilise and she would not have suffered recurrent depression.

The Defendant Trust admitted that owing to her “red flag symptoms” the A & E doctor should have requested an MRI scan, which would have led to surgery within 24 hours.

E agreed on a settlement with the Defendant Trust for £820,000.

The case was reported on Lawtel.

Case Study C

C suffered Cauda Equina Syndrome due to a failure to arrange an MRI scan. C was not taken seriously at the hospital so arranged a private MRI scan but by then the window of opportunity for corrective surgery was lost.

Background

C had a long history of short episodes of back pain. After 4 weeks of lower back pain and 4 days of sciatica, C went to see his physiotherapist.  With no improvement, he also consulted his GP who gave C painkillers.

C’s condition did not improve over the next 4 months, with C requiring stronger painkillers. By now, C was struggling to walk or stand and his sleep was affected.

C’s physiotherapist suspected nerve involvement and referred C for an MRI scan. A few days later C felt a change in his symptoms. There was reduced sensation when wiping his bottom and reduced sensation when urinating.  His bottom was numb and he had shooting pain down his right leg to the sole of his foot. His pain intensified but no MRI scan was performed. Cauda Equina Syndrome was dismissed as a potential diagnosis by the treating doctors.

3 days later C arranged a private MRI scan himself, due to his concern about his deteriorating condition. This revealed a prolapsed disc and an urgent referral to the orthopaedics department was made.  Despite this referral, access to the orthopaedics department of the hospital was refused and C was forced to go through the A and E department.  Ironically a medical student flagged up a suspicion of Cauda Equina Syndrome but this was dismissed by the senior clinician.

By now, C was unable to pass urine, had bowel incontinence, numbness between both legs and there was increased pain in both legs and back. Finally, the seriousness of the situation was appreciated and emergency discectomy surgery was carried out at the L5/S1 level of his spine.

Outcome

C was left with major bowel and bladder problems. C has to manually evacuate his bowel and has incontinence of urine. C has sexual dysfunction, neuropathic pain, increased back pain, reduced walking ability and neurological damage to his right foot and leg. C has a young family but is unable to work following his injury.

C pursued a case in negligence for the failure to perform an MRI scan when he had presented with “red flag” symptoms. The Defendant Trust admitted that there was a delay in diagnosis of Cauda Equina Syndrome and this was responsible for some of the ongoing problems. The case settled for a six figure sum.

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 11^th 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 16^th August 2010 and on 18^th 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.

Case Study D

D suffered Cauda Equina Syndrome due to a failure to transfer D to hospital by the ambulance service despite having “red flag” symptoms.

Background

D pulled her back on 19th July. She felt pain shooting down her right leg to her knee and she had difficulty moving. After a week she had not improved, so she attended her GP. She was diagnosed with acute sciatica and was prescribed pain killers.

D was advised to report to her GP if she developed “red flag” symptoms such as bladder and bowel incontinence and anal and lower limb numbness. On 1 September D was still in pain so her GP referred her to a physiotherapist. The physiotherapist was unable to offer assistance and D was then referred to see a spinal orthopaedic consultant on 28 October. The consultant found that D’s back movements were reduced by 20% of the normal range. D was told she had a nerve root trapped at L5/S1, which meant that there was reduced sensation/sensitivity in her leg. The consultant arranged an MRI scan of the lumbosacral spine and referred D to physiotherapy.

The MRI showed L5-S1 large central disc protrusion causing central canal narrowing and nerve impingement both S1 nerve roots. She had cauda epidural injections and was warned of “red flag” symptoms. She was referred to a consultant in pain management.

By mid-February D’s back and leg pain deteriorated. She saw the orthopaedic consultant again. He booked her for decompression and discectomy surgery on her spine. He warned D of “red flag” symptoms and advised her if she experienced any deterioration in her condition to seek medical review urgently. D was given a copy of the letter the consultant wrote to the GP.

On 30 March D’s condition had become unbearable. She was put on Morphine.

On 1 April D noticed that the nature of her pain had changed. It had spread from one leg to both legs and she had begun to feel numb in her vaginal and saddle regions.

D’s husband called the NHS Direct, explained her symptoms and history and within 45 minutes paramedics arrived at her home. D provided the paramedics with her history and her symptoms and showed them a copy of the consultant’s letter to the GP, to highlight the concerns about Cauda Equina Syndrome. The paramedics informed D that the letter was not for them but she should show it to her GP.

The paramedics did not examine her. They advised that as she was on high doses of analgesics already, they could not administer more pain relief. The paramedics concluded that transfer to an A & E Department was not required and recommended that D consult her GP as he would be able to alter her medication, refer her to a specialist or if necessary arrange direct admission to hospital. The paramedics then left, despite D’s requests to take her to hospital.

On 2 April at 12:08, D contacted NHS Direct again and this time an appointment was arranged for her to be seen at the Emergency Care Centre. She was examined but no investigations were arranged.

On Monday 5 April D contacted NHS Direct at 15:40 and D was advised to call an ambulance. An ambulance took D to the Emergency Department of Queens Medical Centre. By now her symptoms had progressed. There was pain extending to the entire length of her right leg and pain in the left leg extending to the knee. She had associated weakness and decreased mobility. D experienced urinary retention, passing small volumes of urine and also incontinence of urine on a number of occasions. D had 2-3 episodes of faecal incontinence. D had numbness in her “saddle” area but also hypersensitivity.

D was diagnosed with Cauda Equina Syndrome. She was referred for an MRI scan on 5 April under sedation and then she had decompression and discectomy surgery.

By 15 April D reported numbness in her lower limbs. A repeat MRI scan was requested which showed that she had a recurrent disc prolapse at L5/S1.

On 16 April D underwent a re-exploration discectomy decompression surgery at the L5/S1 level.

Following the revision surgery D was unable to mobilise independently, she developed headaches, she was left needing a catheter and was unable to open her bowels. She was discharged home on 19 April.

Outcome

Since being discharged from the hospital, D required crutches to mobilize. D lost sensation in her vaginal and saddle regions and was left with sexual dysfunction.

D suffers from uncontrollable flatulence.  She requires an irrigation system to empty her bowel and she may require a colostomy as she gets older,  D intermittently self-catheterises. D suffers from permanent severe pain in her legs, ankles and spasms in her legs and feet and experiences a pulling sensation in her buttocks. She suffers from muscle weakness and requires morphine for
pain relief.

D pursued a claim against the Defendant for failure to transfer her to hospital for investigation on 01 April. The Defendant conceded that there had been a failure to transfer her to hospital owing to the pain and numbness in her legs vagina and saddle region. The Defendant accepted that if she had been transferred to hospital, she would have had an MRI scan and compression of the cauda equina would have been noted.  D would have proceeded to surgery within 24 hours and the bladder, bowel and sexual dysfunction would have been avoided.  D achieved a 7 figure settlement.

Case Study B

B suffered Cauda Equina Syndrome after a failure  by  the hospital  to arrange an urgent MRI scan on Christmas Eve despite having “red flag” symptoms.

Background

B had a long history of back pain. In September 2013 he consulted his GP when he developed pain in the lower back, both buttocks and down both legs.

His GP told B to come back if his symptoms deteriorated and prescribed him pain killers. From November 2013 B attended weekly sessions with an osteopath but the pain in the back and lower legs worsened. On 10 December 2013 B attended his GP complaining of sciatica in both legs. The GP prescribed
further painkillers and requested an MRI scan.

By the evening of 23 December 2013 B’s symptoms had deteriorated. He noticed difficulty passing urine and getting an erection. He also noted reduced sensation around his anus.

On the morning of 24 December 2013, B noticed the pain had progressed and he was suffering from shooting pains down his legs into his calves with pins and needles. His assessment included an anal tone test. He noticed reduced sensation around B’s anus and groin and difficulty urinating. B attended his GP.

The GP carried out an examination and recorded reduced anal tone, saddle anaesthesia and difficulty urinating.

The GP telephoned the hospital to arrange an orthopaedic assessment and an MRI scan that day, to rule out Cauda Equina Syndrome.

B attended hospital on 24 December 2013 and was seen by a junior doctor. B advised the doctor of his symptoms. The junior doctor discussed the case with her registrar (who significantly did not examine B) and she then performed an anal tone test. Having determined B had normal anal tone, an MRI scan was not
arranged. B was told he was suffering from back pain and was sent home.

B remained in severe pain over the Christmas period. He continued to suffer with numbness and by the new year he had experienced episodes of urinary incontinence.

On Friday 3 January 2014 B finally underwent the MRI scan which his GP had requested on 10 December 2013.

On 6 January 2014, B was contacted by his GP advising that the MRI report showed an L4/5 central disc protrusion. B was urgently assessed in hospital and diagnosed with Cauda Equina Syndrome. Spinal decompression surgery was performed on 7 January 2014.

Outcome

B was left with bowel incontinence, urinary incontinence, sexual dysfunction, neuropathic pain causing electric-shock sensation in both legs, low back pain and stiffness, motor weakness of both feet, when walking, balance disturbance, fatigue and psychiatric illness.

B was married with two young children. He was left with significant ongoing limitations and greatly, diminished his ability to work. B successfully brought a claim against the Defendant Trust for the failure to perform an MRI scan on 24 December 2013. If this scan was performed it would have confirmed compression of the cauda equina and have led to surgery within 24 hours. B settled his case for a six figure sum.

Case Study A 

Mr Gray suffered Cauda Equina Syndrome following a delay in referral to a specialist spinal unit and a delay in performing decompression surgery. He had no long term previous history of back problems prior to developing his condition.

Background

On 7 March Mr Gray began to develop low back pain which became progressively worse and he developed numbness in his right quad. He took painkillers and used a stick to help him walk as he was unable to support his own weight.

On 11 March at 13:30 his legs suddenly gave-way. Mr Gray had weakness in both legs and numbness in his right thigh and back pain. Mr Gray was taken by ambulance to the Emergency Department of Chesterfield Royal Hospital, arriving at 16:36.

Mr Gray was seen at 18:10 by an orthopaedic registrar. He had reduced power in the hips and knees and reduced sensation in his right leg. He had a normal anal tone and no saddle anaesthesia.

Mr Gray was advised he simply had back pain with acute neurological deficit. Mr Gray was advised that he had no clinical signs of Cauda Equina Syndrome. Significantly, A was referred for an X-ray and not an MRI scan, to exclude compression of the spinal cord.

On 12 March, by 08:00 Mr Gray noted that the loss of sensation in his right leg had got worse and now both legs were weaker. A was transferred to a specialist spinal injury unit. However, he did not have an MRI scan until 18:50.

The MRI report confirmed nerve root compression at the L2-L3 level of the spine.

Overnight Mr Gray’s condition deteriorated further and he went into urinary retention and required catheterisation.

On 13 March at 15:10, Mr Gray underwent lumbar decompression surgery.

Outcome

Mr Gray had a significant loss of power in his legs and severe neurological pain. He had bowel urgency but retained normal urinary function. Mr Gray required a wheelchair and crutches. He required extensive personal care in relation to household tasks, specialist aids and equipment and single storey accommodation. Mr Gray was unable to return to work.

Mr Gray successfully pursued a claim for the negligent delay in transferring him to the specialist unit and undergoing emergency surgery. Mr Gray settled his case for a six figure sum. See Video of Mr Gray to find out more about his story.