Delayed cauda equina diagnosis when symptoms aren't apparent

The events

One evening a woman in her fifties, with a history of conservatively managed chronic lower back pain and intermittent sciatica, called an ambulance because of increased pain and numbness and a loss of power in one leg. The paramedic crew who attended contacted the patient's GP practice to summon the doctor-on-call, because they did not believe that admission to hospital was necessarily indicated, and the member (who was not the patient's registered GP) visited.

On arriving at the patient's address, the GP found the patient seated on the ground-floor doorstep, attended by the paramedics. (Not having a phone of her own, the patient had made her way down to the street from her first-floor flat to summon a passing motorist for help in calling an ambulance.) The GP member explained that she needed to examine the patient and the patient made her way up the stairs to her flat and – with some assistance from the paramedics – lay down on the bed.

The doctor examined the patient, carrying out straight leg-raising tests and asking her whether she had difficulty urinating – she said she did not – and could she move her toes – she said she could. The doctor decided that the pain the patient was experiencing was entirely consistent with her previous history of lower back pain and – in the absence of any further specific symptoms – explained to the patient that admission at that point was not indicated. Before leaving, she gave the patient a prescription for an oral analgesic. (The note the doctor made of the visit was not subsequently available in the patient’s records and appeared to have been lost, although the practice receptionist confirmed that a note had been made at the time.)

Later the same evening, the GP member took an out-of-hours phone call from a close friend of the patient, who expressed surprise that the patient had not been admitted to hospital. The GP member was unable to discuss the patient's condition in detail because of her duty of confidentiality to the patient, but explained the local guidelines relating to the care of patients with acute back pain, highlighting that the GP should be contacted urgently if the patient deteriorated or failed to improve. (Again, the note of this phone conversation was subsequently not available in the patient's record.)

The next day, the patient requested a further home visit and her own GP, a member of another medical defence organisation, came to see her at lunchtime: he found the patient lying on her bed, clearly in pain; the patient was able to move her feet and – according to the doctor – denied any bowel or bladder disturbance. The second GP recalled that he advised the patient to continue with oral analgesia but to contact him immediately if there was any loss of bowel or bladder function. No contemporaneous notes were made.

The following day the patient again called for an ambulance in the evening and was admitted to hospital with, according to the admitting registrar’s note, "cauda equina syndrome of 20 hours' duration". A L3/L4 laminectomy was performed; although there was no initial improvement, the patient eventually recovered continence but was left with diminished power in both legs and perineal anaesthesia.

Claim and trial

Some three years after the events in the case, both the member GP and her colleague received notifications of a claim against them, alleging negligence through missed diagnosis and consequential loss of mobility following delayed surgery. It was alleged that, in light of the patient's presenting symptoms, the GPs should have admitted her to hospital earlier, following which she would have had surgery earlier with a better outcome.
 
The case against the MDU's member was essentially that she should have thought of cauda equina syndrome as soon as she saw the patient, or at least following the late-night phone call from the patient's friend – the only two occasions on which she had dealings with the case. The case against the second GP, who had seen the patient the following day, was that he should have suspected cauda equina when he saw the patient.

The MDU sought the opinion of a GP expert witness to clarify whether the member GP had provided care of an appropriate standard when visiting the patient and taking the phone call. The GP expert agreed that, based on the GP member’s statement and the hospital records, the care had been entirely appropriate.

The key issue was the timing of the member's visit relative to the likely onset of the cauda equina syndrome, and what signs and symptoms had been present when she had examined the patient. According to the patient's subsequent statement, the onset of abnormal bladder symptoms and paralysis of the legs had been late in the night on which her friend had phoned the member GP. Admission notes from the A&E department two days later indicated cauda equina syndrome of some 18 to 20 hours' duration.

This meant that the onset was long after the member GP's visit, when questions about bladder function and toe movement had eliminated cauda equina syndrome (CES) from consideration, and also after the phone call from the patient's friend.

In the case of the late-night phone call from the patient's friend, GP experts instructed by both defendants agreed that, as the patient's friend had not communicated to the member any symptoms suggestive of CES, no further action had been indicated over and above the advice given.

The GP expert witnesses agreed that a doctor should aim to exclude the suspicion of a diagnosis of CES by establishing whether a patient is presenting with bladder or bowel disturbance or progressive neurological signs – such as reduction in perineal sensation. They also agreed that, while signs and symptoms such as these would be indications for an immediate admission, their absence in this case meant a visit or hospital admission were not called for. Further, they agreed that questions of paraesthesia and saddle sensation would be asked only after questions about disturbed bladder and bowel function, to which in this case the answers were negative.

Following a detailed consideration of the case with a solicitor and barrister, instructed by the MDU, the GP member wished to defend the claim and the matter proceeded to trial.

The outcome

The trial judge opined that, despite the absence of contemporaneous notes from the patient's records, the evidence of the two GPs about the events surrounding the onset of the patient's intensified pain and the examinations and verbal exchanges at the time was more credible and reliable than that of the patient, whose evidence at trial was in several respects at variance with her written statement.

The judge further opined that, while a consultant neurologist might have detected abnormal signs in the patient, which the two GPs did not, they should both be judged by the practice of a reasonable GP and not by that of a neurologist.

Deeming the two GPs to be "careful and diligent practitioners who carried out detailed examinations" and "caring doctors", and judging that there had been no breach of duty on the part of either doctor, he dismissed the case against both GPs.

As the claim was publicly funded, the defence costs incurred by the MDU on behalf of our GP member – totalling more than £50,000 – could not be recovered.

Risk Management note:

In this case, notes by both defendants about visits to and examinations of the patient were missing from the patient's record. In spite of this, the case was successfully defended, thanks to the clear accounts given by the doctors involved and the notes in the hospital record. It is important to make notes following home visits and phone calls, and to ensure that these areplaced in the clinical record, in order to enable the patients to receive appropriate clinical care at all times; such notes may also be helpful if a complaint or claim is made.

Reference

  1. Article "Cauda Equina Syndrome: diagnosis delay and litigation risk" as featured in the MDU Journal, volume 20, issue 1, July 2004.


This guidance was correct at publication 01/12/2006. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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