A GP was found to have negligently failed to spot 'red flags' of cauda equina syndrome in the recent case of Shaw v Stead, where judgment was given on 1 March 2019. It seems that the condition being missed in primary care or emergency departments is one of those mistakes that repeatedly result in claims.
In cauda equina syndrome, compression of the bundle of nerves at the base of the spinal cord can cause serious disability. There are certain well-known red flags:
The claimant, Mrs Shaw, was working in a school. On Thursday 23 May 2013, a pupil with special needs kicked as she was squatting down. She fell forwards and then twisted her back as she got up. Her back immediately felt very painful.
The next afternoon (Friday, 24 May 2013), she consulted a GP, who prescribed her painkillers. The following day (Saturday 25 May 2013), she telephoned the surgery at 15:16. Mrs Shaw spoke to a nurse who recorded, "Today legs have gone numb, tingling..." Half an hour later, she telephoned again. She was advised to attend the out-of-hours GP service, although this time nothing was recorded to suggest loss of feeling in her legs.
Mrs Shaw's husband took her to the out-of-hours service, where she saw Dr Stead. He understandably could not remember this appointment, and there was a conflict of evidence between the GP's record and Mrs Shaw's evidence. Mrs Justice Yip considered the evidence very carefully and she was helped by experts in general practice and neurosurgery.
Mrs Stead said she had been in such pain that she went to the appointment in a wheelchair and needed to be helped onto a couch. Dr Stead's note did not make any reference to a wheelchair and he thought in evidence that attending in a wheelchair would have been significant enough to record. The judge accepted her account on these points. Dr Stead's note included the history and the words' no red flags'. He said this meant he must have tested for them. His diagnosis at the end of the consultation was sciatica. Dr Stead advised changing painkillers.
In weighing the evidence as to what symptoms Mrs Shaw presented with, Mrs Justice Yip thought there were two important factors in Mrs Shaw's testimony. Both suggested red flags were present. First, earlier on that Saturday, while her husband was outside cutting the grass, she managed to get up to go to the toilet but was unable to pass urine. However, Mrs Shaw then had a urinary accident on the way back. Secondly, she described difficulty walking when she got up to go to the surgery. Her legs felt weak and she described feeling 'like Bambi'.
After the weekend, she called the out-of-hours service on Monday 27 May 2013. She was struggling to walk. According to the note of that call, her legs felt "cold and like jelly". She then saw a doctor who noted a loss of power and sensation. On advice from the on-call surgical registrar, he sent her to Accident and Emergency. She underwent MRI scanning, which showed a large central disc L3/4 prolapse. She was transferred to another hospital, where she underwent emergency neurosurgery.
The trial concerned only the limited issue of whether the doctor had breached his duty. The judge did not, therefore, address issues of causation and quantum.
There was no issue between the parties regarding the legal test applicable to Dr Stead's care (the Bolam test) or what standard was expected of a GP in these circumstances. A GP seeing a patient with acute back pain was under a duty to carry out an examination and check for any red flags. If red flags were present, the patient should be sent to hospital for MRI scanning and then, if necessary, undergo urgent spinal surgery. If they were not, she should be advised to seek urgent medical attention should the condition change and any red flag symptoms develop.
Here, the GP was found to have breached his duty on this occasion by failing to note red flags of cauda equina syndrome and refer Mrs Shaw urgently to hospital.
Cauda equina is, of course, a serious and potentially disabling condition. With prompt diagnosis and treatment, patients can make a good recovery, although treatment tends to prevent the condition from worsening rather than restoring them to their previous state. Delays in diagnosis risk avoidable harm.
The key is noting whether there are 'red flags' present, investigating by MRI scanning and then urgent spinal surgery. Regrettably, delays in diagnosing cauda equina syndrome are among the relatively common scenarios that give rise from time to time to clinical negligence litigation. Shaw v Stead is one recent example.