Born in 1976, our client X had suffered with sciatica for many years. On 4th February he was walking across the front room of his flat to go to the toilet when his right leg went into spasm and gave way under him.
He fell back against the wall and slid down straight onto his backside. He was in significant amounts of pain but was able to get back to the sofa and lie down. When giving his initial witness statement, X could not recall whether he had managed to go to the toilet before returning to the sofa, but he remembered having a sense of numbness and tingling in his genital area and sharp pains in his back and down both legs.
X called an ambulance and it arrived at about 10.30 am. He was taken by ambulance to the accident and emergency department at the first hospital and arrived there around an hour and eight minutes later.
Cauda Equina
At 11.45 am he was given Tramadol on account of the severity of his pain. At about 12.55 the Claimant was reviewed by a doctor who recorded a history including ‘bilateral numbness in low back legs, cannot feel buttocks, passed urine but could not feel it’. The doctor’s impression was of a “cauda equina” injury which he flagged in the records with a number of star signs. The doctor requested an orthopaedic review and X was reviewed by a junior orthopaedic doctor at 15.00. At that stage there had been no urinary incontinence but the altered perianal sensation was noted. The doctor’s plan was to arrange for an urgent MR scan, which was requested at 15.17 and X underwent the scan of his lumbar spine at 15.59. The scan showed a large central posterior disc protrusion at LS/S1 causing compression of the cauda equina. The orthopaedic doctor was made aware of these findings at 16.00 and at 17.00 X was admitted to a ward at Stepping Hill Hospital and was diagnosed as suffering from cauda equina.
At about 17.00 the orthopaedic doctor attempted to contact the on-call spinal surgeons at the second hospital (which was a regional specialist unit) by telephone for approximately 45 minutes. He was unsuccessful in getting hold of anyone and his calls were not returned. At 19.00 the orthopaedic doctor telephoned the second hospital again and managed to speak to a spinal surgeon and then forwarded a copy of X’s MR scan across to that surgeon electronically. The doctor at the second hospital did not immediately accept the diagnosis of cauda equina and asked the junior orthopaedic doctor at the first hospital to re-examine X and come back to him.
After the orthopaedic doctor had re-examined X he attempted to contact the spinal surgeon again by telephone but found that he was not available. He was told he needed to call the on-call neurosurgeon at the second hospital and he attempted to do so. When he spoke to a neurosurgeon that neurosurgeon could no longer see the MRI images on the electronic system and therefore he did not get back to the orthopaedic doctor until 21.00.
Urinary incontinence
At 22.00 the Claimant suffered an episode of urinary incontinence despite not having had any sensation of his bladder filling up to that point. A different junior orthopaedic doctor had come on duty by that time and he liaised with the second hospital to have X transferred there and he arrived at the second hospital at about 01.00 on 5th February. He was reviewed by a specialist registrar in neurosurgery 2 ½ hours later and operated on at about 10.00 on 5th February. It was alleged that the negligent party was the second not the first hospital as the second hospital had not taken proper responsibility for a patient who not only was showing red flag signs but had also been identified as a potential cauda equina patient (which diagnosis had already been confirmed by way of an MR scan).
Breach of duty and causation was denied by the defendant hospital NHS Trust until only a few weeks before trial. It was argued that the actions of the doctors at the second hospital were reasonable. It was also argued that even if they had responded to the calls of the first hospital earlier X would still not have come to surgery until roughly the same time that he did and therefore his outcome would not have been any better.
As it was, X developed and continues to suffer from neuropathic pain, numbness affecting both legs, bladder and bowel dysfunction and sexual dysfunction.
Joint Settlement Meeting
The case proceeded to a Joint Settlement Meeting. The main argument between the parties related to the time at which X was considered to have reached the point at which even with surgery he could not have recovered any better than he did. The Defendants argued that “urinary problems” had started from 10.00 am on the morning of 4th February and therefore even if surgery had taken place before midnight on that date, his outcome would have been no better. By contrast, it was argued on behalf of X that he would only have. passed the point of no return, in terms of the surgery benefiting him, at the time he suffered an episode of overflow incontinence. With cauda equina syndrome (CES) a patient cannot feel their bladder filling and it will therefore get so full that the patient cannot help but have an episode of incontinence, all without any sensation. Whilst X remembered having an episode of incontinence at around 22.00 on 4th February, it was argued that this was not overflow incontinence and could not have been as he had been nil by mouth since he had been admitted to hospital.
As with all of the cauda equina cases we deal with, the arguments on causation were not straightforward. In this case, whilst it was eventually admitted by the Defendant Trust that the doctors at the second hospital failed to act appropriately from 17.00 onward on 4th February, the issue was whether surgery before midnight on that date (which should have occurred) as opposed to at 10.00 the following day (when it actually took place) would have altered the outcome.
Settlement
Just less than one week before trial the Defendant eventually agreed to settle the case at a compromise figure on the basis that there was a greater risk to them than the Claimant that the court would find that surgery some 10 hours earlier would have led to the Claimant having less issues with his bladder, bowel and sexual function and lower limb neuropathic pain and reduced mobility.
Due to the specific circumstances of this case, the value of the claim was not as high some cases involving cauda equina injuries and it was disappointing that the Defendant took so long to agree settlement of the case.
Lesley Herbertson, Clinical Negligence Partner here at Hugh James who acted on behalf of X, said:
We see here a specialist unit not accepting that a patient was presenting with red flag symptoms and a clear diagnosis of cauda equina injury despite the investigations performed and evidence provided by another hospital. If specialist units are not able to act appropriately in these circumstances, then there is no wonder that GPs and/or district general hospital staff can often fail to pick up on the warning signs as quickly as they might.
The names and identifying details of the client have been changed to protect the privacy of individuals involved.
