Shaw v Stead – A Case of Missed Cauda Equina Syndrome
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 1st March 2019. It seems that the condition being missed in primary care or emergency departments is one of those mistakes which repeatedly result in damages claims.
Cauda Equina Syndrome
In cauda equina syndrome compression the bundle of nerves at the base of the spinal cord can cause serious disability. There are certain well-known red flags:
- Altered sensation in the saddle area;
- Impairment of bladder or bowel function;
- Loss of power in both legs; and
- Pain or loss of feeling in both legs (but not just one).
Shaw v Stead
The Claimant, Mrs Shaw, was working in a school. On Thursday 23rd 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 24th May 2013) she consulted a GP who prescribed her painkillers. The following day (Saturday 25th May 2013) she telephoned the surgery at 15:16. She spoke to a nurse who recorded, ‘Today legs have gone numb, tingling..’ Half an hour late 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.
Her husband took her to the out of hours service where she saw Dr Stead. Dr Stead 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 include 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. He advised changing painkillers.
In weighing the evidence as to what symptoms Mrs Shaw presented with, Mrs Justice Yip thought there were 2 important factors in Mrs Shaw’s testimony. Both suggested red flags were present. First, earlier on that Saturday whilst her husband was outside cutting the grass, she managed to get up to go the toilet but was unable to pass urine. However, she 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 27th 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 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 Dr Shaw had breached his duty. The judge did not therefore address issues of causation and quantum.
There was no issue between the parties as to 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 urgently 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 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 one of the relatively common scenarios which give rise from time to time to clinical negligence litigation. Shaw v Stead is one recent example.
 Shaw v Stead  EWHC 520 (QB)