Liability admitted by hospital for negligent delay in diagnosis of Cauda Equina Syndrome

We have secured an admission of liability from North Middlesex Hospital that it failed to properly assess a patient on two occasions. This led to a delay in diagnosis of Cauda Equina Syndrome, a condition involving spinal discs compressing sensitive nerves that can cause permanent damage if not swiftly treated by surgery.

Our client had a past history of low back pain which recurred in December 2012. On 20 December he suffered increasing back pain throughout the day and started to have difficulty in fully emptying his bladder but at this stage had full sensation. The pain in his buttocks also spread down the back of both legs and he developed abdominal discomfort. By the early evening he became aware of a numb sensation around his genitals and buttocks. 

His wife carried out some internet research which revealed that his symptoms of numbness in the genital area, pain in the back and pain in both legs together with problems passing urine could be an urgent condition. Prompted by this, our client called the out of hours service which correctly suspected and documented the suspicion of Cauda Equina and told him that he urgently needed to attend A&E. 

He was subsequently triaged at the North Middlesex University Hospital A&E where it was noted that  he had sciatica, difficulty urinating, pain in the back of his legs and numbness in his buttocks and groin. It was almost four hours before he underwent medical review. When seen by the doctor, our client and his wife explained his symptoms and also told the doctor that the NHS website had described his symptoms as ‘red flag symptoms’.

The A&E doctor carried out an abdominal and rectal examination and made a diagnosis of constipation. He noted only 'tightness of the perianal region' but did note that it was 'difficult to pass urine'. The doctor did not carry out any sensory testing, neurological testing, power or reflex testing.

The A&E team referred our client on to the surgical team and a review was carried out. Our client repeated his history and symptoms and his wife again raised the issue of the NHS website referring to these symptoms as being red flag. The surgical doctor carried out an abdominal and rectal examination but did not carry out any tests on our client’s lower limbs, although he noted bilateral limb pain. Our client was advised that the bowel and bladder problems were likely to be as a result of the amount and variety of painkillers that he was taking and he was later discharged.

By Christmas Day morning our client was in so much pain that he re-attended at the A&E department. The triage note refers only to him suffering from constipation despite our client’s reiteration of his history of back pain and the development of the symptoms of urinary problems and numbness. He was immediately referred to the surgical team without review by an A&E doctor. The surgical notes relate entirely to constipation with an examination consisting only of an abdominal examination. A repeated diagnosis of constipation secondary to opiates was given and he was discharged.

Two days later, our client had his planned appointment with his spinal surgeon who arranged an urgent MRI scan which confirmed the presence of Cauda Equina compression. Our client later underwent surgery.

Since these events our client has been left with problems with his bladder and bowel function and sensation and function in his lower limbs. 

We presented a claim to the hospital that, on both 22 and 25 December 2012, our client presented with a constellation of symptoms, including clear ‘red flag’ symptoms that should have prompted an immediate consideration of the possibility of Cauda Equina Syndrome.

This should have led to an immediate referral to an orthopaedic team, arrangement of an urgent MRI scan and, should the MRI scan confirm radiologically the diagnosis of Cauda Equina Syndrome, referral on to a neurosurgical team. It was alleged that there was a complete failure to recognise the symptoms as indicating potential Cauda Equina Syndrome and to consider this diagnosis together with a repeated failure to carry out a full and proper assessment.

It is our client’s case that, had appropriate care been provided, on the balance of probability, he would have had full control of his bowel and bladder post surgery. At worst, there may be been some loss of sensation in his genital/groin/buttock area but not to the same extent.

The trust has responded in a timely fashion to admit the allegations of negligence made against it in full and both parties are now proceeding to assess the impact of the delay upon our client and the value of his claim.

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