Claim settled against Isle of Wight NHS Trust for failing to advise patient of Cauda Equina Syndrome symptoms
We agreed the settlement of a claim against St Mary’s Hospital, Isle of Wight, for the alleged failure to appropriately advise our client of “red flag” symptoms of Cauda Equina Syndrome when she was discharged from A&E in July 2012. This caused a delay in diagnosis and decompression surgery to treat her condition.
In or around May 2012, our client developed an onset of significant lower back pain for the first time, which continued to increase in severity. She attended her GP surgery and St Mary’s Hospital on a number of occasions to express her concerns about her increasing back pain. Each time she was advised that she was suffering with “common back pain” and there was little that could be done to help her. She was advised to take painkillers and that, eventually, her symptoms would settle.
Her symptoms continue to progress over the subsequent weeks however, and she began to develop left-sided sciatica. By the latter part of July 2012, she had developed bilateral leg pain and numbness. Our client was understandably very concerned about the evolving nature of her symptoms and, after a brief telephone discussion with NHS 111, she was advised to attend her local A&E department as a matter of urgency.
She was seen relatively promptly by a doctor at A&E to whom she reported the severe lower back pain that she had been experiencing since May 2012, and that she had developed an onset of bilateral leg symptoms in the last few hours. It was evident from the medical records that the clinician did consider the possibility of CES due to the nature of the examinations performed.
However, it appears that the doctor did not consider that her condition required any further investigation at A&E or that she required urgent treatment. She was discharged with a recommendation that she needed an MRI scan which her GP should arrange for her. Our client was further advised on her discharge that, if she was to “wet herself” (incontinence), she should return to A&E. Other than this, no further advice was provided about the other symptoms of impending CES or what she should do if they were to arise. She was provided with various pain medications in hospital, which made her feel nauseous and unwell.
After being discharged from A&E, our client was in extreme pain and, being unable to care for herself, she stayed with her parents over the subsequent week. However, her condition deteriorated and she began to suffer with an altered sensation that she was unable to fully empty her bladder. Although she was aware of the advice to attend A&E if she wet herself, as she was having the reverse difficulty, she was not unduly concerned, and attributed the difficulty of emptying her bladder to her pain.
Approximately two days after her discharge, our client then experienced an onset of “numbness in the genital area” together with loss of sensation when passing urine. She was not aware of the significance of these symptoms at the time. Over the subsequent days, she remained in bed in extreme agony with her back, and feeling very sick, to the extent that she was unable to eat or keep water down.
Approximately a week later, our client attended a routine appointment at spinal triage. During this appointment, a history was taken of her evolving symptoms and the clinician appreciated the severity of her condition and arranged an urgent same day MRI scan. The scan findings were reported to be consistent with CES and she was consequently transferred to the specialist neurosurgical team for decompression surgery. However, by the time she was seen by the specialist team, it was considered that, given the delays in diagnosis, she was likely to be “beyond help”.
Remarkably, our client made some improvement post-surgery but has been left not only with significant issues with pain and mobility, but also with bladder function as, although she experiences the sensation of urgency, she cannot feel the passing of urine and has experienced episodes of incontinence. She also has problems with bowel and sexual function.
We were instructed to investigate her concerns about the treatment she received, particularly in respect of the advice she was given during her A&E attendance in late July 2012. We commissioned an independent expert who was critical that the only advice given to her on discharge was to return if she developed “urinary incontinence”.
Our expert was of the opinion that the treating A&E doctor was clearly considering the possibility of CES and, if he was happy that this possibility had been ruled out on the day, then any reasonably competent A&E clinician would have ensured that our client was made aware on discharge of the “red flag” symptoms and, should they develop, to return to A&E urgently. These symptoms included:
Our expert said that these are obligatory for safety netting and that any reasonably competent doctor would advise the patient to come straight back to A&E if any (ie one or more) of these symptoms were to develop. Had our client been appropriately informed upon her discharge, she would have re-attended A&E at an earlier stage and would have undergone decompression surgery before her symptoms deteriorated further.
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