Anonymised Cauda Equina Report

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Mr D. A. Campbell BSc. MB. ChB. FRCS. FRCS(Ed).


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MEDICAL REPORT



RE:BBO


DATE OF BIRTH:12th  Never 9999


OCCUPATION:Disabled 


ADDRESS:



SUBJECT OF REPORT:Alleged Medical Negligence 12//9999



INSTRUCTING PARTY:Suem & Grabbitt, Solicitors



SOLICITOR REFERENCE NO: !



OUR REFERENCE:DAC.DNS.208xxxx


DOCUMENTATION REVIEWED: Records from  M University Hospital


Records from  J  Hospital


Records from  N Rehabilitation  Hospital


Report of Mr. AS Consultant in Accident and Emergency Medicine

Report of PJR, Consultant in Accident and Emergency Medicine


Report of Mr HS Consultant Orthopaedic Surgeon


Appendix I



Mr D A Campbell FRCS (London)  FRCS (Edinburgh)



Appendix I

 

 

Mr D A Campbell FRCS (London)  FRCS (Edinburgh)

 

 

Graduate of Edinburgh University Medical School.

 

Full-time NHS Consultant Neurosurgeon for 12 years until 1996 and thereafter remains in active medicolegal practice in Harley Street.

 

Special interest in Cervical and Spinal Surgery, missile injuries to the head and spine, and stereotactic surgery.

 

Involved in postgraduate lecturing to doctors and lawyers involved in medico-legal issues

 

Extensive experience in medico-legal work, having given written or oral evidence in excess of 5000 cases.

 

Trained and experienced with regard to CPR procedures, and has wide experience in compliance with orders of the Court regarding medical evidence in personal injury cases.

 

 Experienced in producing medico-legal reports relating to personal injury claims, being instructed by claimant and defendant representatives, as well as receiving joint instructions.

 

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Expert Witness Directory

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Expert Witness Website

 

G.M.C. Registration                No. 1333231(S)

 

Professional Indemnity Insurance Hiscox Insurance

 

Waiting list approximately eight weeks.  Available for medicolegal consultation at private consulting rooms and hospital in London, Birmingham, Brighton, Derby, Gloucester, Manchester, Newcastle-under-Lyme, Norwich, and Sheffield.


I have been supplied with a series of documents as listed above. 


Prior to the events to which this report refers the documents have been supplied with include S Hospital records, MM Hospital records, R Hospital Records, H Hospital records, general practice records.


I shall comment on these in turn but I cannot comment on the x-rays and scans as I have not been supplied with the images, 



Prior to the events to which my report will refer in  the records to suggest suggest that this lady had any significant previous medical history in relation to her back.  There is no reference to any other unrelated medical condition such as diabetes or  prior neurological illness, nor any family history suggestive of spinal-cord dysfunction. Whilst I appreciate the necessity not to duplicate matters and necessarily, I think it is useful at the start to give a very abbreviated history to which I may refer in my conclusions.


1 ABBREVIATED HISTORY:


1.1 Mrs BBO had been previously healthy and had developed some back pain in association with her pregnancy. This is not uncommon and there is nothing to suggest that the back pain was anything other than normal during the pregnancy. She was delivered of a healthy infant by Ventouse  extraction after quite a relatively short labour. Following this she  then began to become aware of some pins and needles in her left leg. She was advised that this was not uncommon after a difficult labour by the maternity staff, and went home in the normal way.  She complained of some back pain over the next few months,  but there was a sudden deterioration in her back pain, associated with the change in the location of the pain which occurred spontaneously on xxxxxx. There does not appear to have been any specific precipitating cause at this point. It is important to recognise at this point that there was a significant changes in the nature and intensity of symptoms. Because of this  an emergency ambulance was called and she was taken to the M hospital in =.  Casualty records confirm her arrival at 18:47 hours on xxxxx. The ambulance record which accompanied her noted that she had pain radiating down the legs, that she had a “weak right knee” and that she had last eaten at lunchtime. The ambulance crew noted that the back pain subsequent to the delivery of the child had been “mild” and the diagram indicated right sided back pain and knee pain. There is no record of any clinical examination or medical or nursing notes for this attendance. I understand that she was left in a wheelchair for four hours and when asked how long she was likely to wait was told that it was likely to be all night. She was advised to go home and contact a general practitioner in the morning. This she did, but approximately 3 o’clock in the morning the pain became very much worse and she was unable to stand or walk. She was taken by her husband back to the M Hospital where she waited for two hours, saw patients who had been there when she attended previously that night, but I understand that she was not seen by any nurses or doctors and after two hours went home. There are no casualty records for this attendance. By 9 AM on xxxxx she was advised on the telephone by her general practitioner to go back to the M Hospital, and on arrival found the same patients from the night before still waiting in the casualty department. She therefore went to the accident department at J Hospital where  records  confirm her arrival at 10:33 hours on xxxxx. There the admitting doctor carried out a careful and appropriate examination noting inability to walk for one day dragging of the right foot and disturbed perineal sensation and bladder dysfunction. Quite correctly he made repeated requests for the orthopaedic department to see her at 13:45 and 14:15  (twice) and it would appear that it was not until 18:10 hours that the orthopaedic registrar saw her and made arrangements for transfer to the M  hospital for urgent assessment and MRI scan ambulance records confirm her transfer but not the time of arrival. A hand written medical note, however, is timed at 19:26 hours showing significant weakness of both lower limbs and complete absence of sensation in the right leg and the decision is made for an emergency MRI scan which showed compression of the Cauda Equina. She was taken to theatre for emergency decompression and the anaesthetic record suggests the operation was started at approximately 21:30 hours. The operation note itself is entirely standard and her post-operative course is unfortunately one of persisting lower limb weakness urinary incontinence (for which she has to self catheterise)  and bowel urgency although I understand that she is  continent of faeces providing she can open her bowels for times per day. I also understand that she is severely limited in mobility and has extreme difficulty in looking after her young baby and requires constant help with this.



2 Commentary on the sequence of events:


2.1 Cauda Equina syndrome is a frequent source of actions for alleged medical negligence. It is a condition the seriousness of which is taught to every undergraduate and emphasised as being serious and time critical to every medical student in Britain and Ireland. It is a condition we are general practitioners, although unlikely to see more than one case in their professional lifetime, unexpected to be aware of the very serious consequences of misdiagnosis or late diagnosis. I would say at the outset that I do not believe that the general practitioner in this case can be criticised, nor do I believe that the obstetric care staff can be criticised.


2.2 What is concerning, however, is the effect that the complete failure to recognise the condition and the subsequent unnecessary delay in surgical intervention which flows from that. I appreciate that experts in accident and emergency have already expressed their opinions in this matter and I would say for completeness but I have read the reports by PR and Mr S, and whilst I defer to their expertise I would see that I agree entirely with their assessments.


2.3 The question therefore must arise as to the effect of delay in this matter, and an estimate has to be made of the likely point in time at which the Cauda Equina syndrome began, and the likely outcome had surgery and undertaken in a timely and appropriate manner. Before commencing my assessment of this, I must say that there are two large groups into which Cauda Equina  syndrome fall. The first is the rapid onset in which there is a relatively short time between onset of severe pain or dramatic change in a pre-seeding back pain and the onset of bladder and bowel and motor problems. In round terms patients in whom the progress is faster than 24 hours fall into this group. The second group are those in which the symptoms are more prolonged and of more gradual onset, anything up to a week or two weeks. There is considerable debate even now as to the significance of this division in the rapidity of onset. Some research papers have suggested that the slower onset group have a better clinical outcome when surgery is undertaken than the first group were the symptoms come on extremely rapidly. This is by no means generally accepted as there are insufficient numbers in any individual report of Cauda Equina  syndrome to provide an answer which attains statistical significance.


2.4 There has been a very useful publication produced by Blackwell scientific publications “medical negligence the brain and spinal-cord” edited by Garfield and Earle.  These authors (one medical and one a Queen’s Counsel) essentially say that the condition has to be recognised quickly and that even if a patient has fallen into the rapid onset group and has gone past 12 hours since the onset of complete cauda  equina syndrome, it would be unethical and medically indefensible to delay surgery even to the next morning in order to have specially trained staff undertake the procedure. I am happy to provide a photostat copy of the full article for the guidance of the court.


2.5 There has also been a meta analysis of available research papers undertaken in the British medical Journal which comes to the same conclusion, and essentially says that no delay in surgical decompression is acceptable.


2.6   I shall now address the question of what I believe to have occurred and what the effects of surgery at the periods points on the balance of probabilities would have been. The most important factor which should alert any competent nurse or doctor to the possibility of Cauda Equina syndrome is a sudden and dramatic increase in severity of symptoms with no obvious precipitating cause. From the information available to me I believe that an acute disc protrusion occurred around midday on xxxxx when the pain suddenly became worse, went into both legs, and numbness developed in the legs. This was clearly recorded in the M Hospital casualty records “week right knee. Pain radiating down leg. Past medical history ……… Pain score 7/10”. This has been recorded by nurses and any reasonable nurse would then inform a doctor that the patient required to be reviewed urgently. This did not happen and there are no medical notes. If the patient had been recognised at this point as having a developing (and at this point by no means complete) Cauda Equina syndrome, I think it is reasonable to say that within one hour a doctor would have examined the patient and recorded perianal sensation motor power reflex changes and bladder function. If the patient was unable to pass urine normally a catheter would be inserted and residual volume of urine recorded. This would give the clinical diagnosis after which an emergency 

MRI scan would be ordered and I would estimate that this could be done within one hour. At that point the need for emergency surgery would become obvious and necessary to prevent progress of the Cauda Equina syndrome and the patient would have been kept starving and not allowed to drink from the point where the MRI scan was requested. I would estimate that even in the worst circumstances within two hours of the MRI scan being undertaken the patient would be in the theatre having the necessary decompression. If that sequence of events had been followed in essence the patient would have been on the table within four hours of arrival at casualty. The outcome would almost certainly have been that bladder function would have been preserved, she would have been able to walk perhaps with some limitation on walking and standing distance, and she would have been led to some mild back discomfort that might have restricted mobility or prolonged sitting but which would have allowed her certainly to get back to work in an office environment, and to look after her young baby with only minimal support.


2.7 This did not occur, and it was only at 10:30 hours on xxxx that she was seen in J Hospital and I would congratulate the doctor and nursing staff on picking up what was clearly going wrong and acting appropriately and in a timely fashion. No criticism can attach to the accident and emergency doctor or nurse on that occasion. I am, however, very concerned about the complete lack of urgency being shown by the orthopaedic registrar. It is clear that the accident department doctor was very worried and repeatedly attempting to get the Orthopaedic registrar to see the patient. This did not occur until 18:10 hours on xxxxxxx. This means that a further eight hours were wasted and by the time Mrs BBBO was recognised as having a potential Cauda Equina syndrome, that syndrome had become complete. Had she been seen by the orthopaedic registrar by 11:30 hours a seven hour delay could have been avoided. I believe that allowing for appropriate decompression at that point she would have been left with urinary urgency some weakness of the legs probably requiring the assistance of a stick to walk significant distances and more back pain but she would still have been able to manage herself without self catheterisation and would have been able to look after her young child with more help than would have been required earlier but less help than she now needs.


2.8 Having been transferred to the M Hospital it is clear that someone somewhere had fed the patient and given the patient  a cup of tea. This would delay the onset of the anaesthetic, but it is not entirely clear to me to decided to do this. Be that as it may,  having arrived at the M Hospital at 18:49 hours,  it seems unusual that it took almost 2 hours to get her onto the MRI scanner particularly as this must have been out of hours. It also seems quite a long time to have taken almost an hour and a half to get her from the scanner into the operating theatre. In normal practice if a suspected Cauda Equina syndrome case is on its way any reasonable registrar would warn the scanner that scan was essential, and warn Theatre to be ready to take the patient as quickly as possible after the scan results were available. This seems to suggest that there was a lack of urgency even in the M Hospital as it seems to have taken almost 2 hours to get her into theatre. It is a matter of general principle that the longer a patient is left with either a partial or complete Cauda Equina syndrome the worse the outlook is, and although I appreciate that lawyers would like to be able to identify points in time at which a specific deterioration which was avoidable could be identified, the truth is that the deterioration tends to be a progressive deterioration rather than a stepwise one – hence the need to avoid any unnecessary delay at all points in the chain of events. I would say, however, that once the patient got into theatre the surgery undertaken was appropriate and I would have no criticism of it.


3 Conclusions:


3.1 Mrs BBO has been left in a dreadful state as a result of repeated delays in the diagnosis of her condition, allowing a partial Cauda Equina syndrome to become established, and even once established there was an avoidable delay in obtaining timely decompression which all reasonable medical opinion would accept will have resulted in further and avoidable neurological deterioration which has left her with more severe symptoms than she need have. She has had appropriate and intensive rehabilitation and although I would defer to the opinion of a rehabilitation expert, I do not believe that there is any criticism that can be made of the rehabilitation services. I should be happy to assist further if the court wished in further clarifying these events.



I understand my duty to the Court and have complied with this and will continue to comply with it and I am aware of the requirements of Part 35 and Practice Direction 35, this protocol and the Practice Direction on pre-action conduct.


I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not.  Those that are within my own knowledge I confirm to be true.  The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.



MR D A CAMPBELL, BSc MB ChB FRCS FRCS[Ed]





Consultant Neurosurgeon



REFERENCES:


NICE Guidelines for the treatment of Impending Lumbar Disc and Cord Compression: www.nice.org.uk/ nicemedia/pdf/ CG75QuickRefGuide.pdf · PDF file


NICE clinical guideline 75 Developed by the National Collaborating Centre for Cancer. ... – neurological signs of spinal cord or cauda equina compression.


Medical Negligence The Cranium, Spine and Nervous System (Ed. Garfield & Earl) Blackwell Science  pp 137 - 143 & 146 - 148


Surgery of the Spine, (Ed. Findlay & Owen) Blackwell Science pp103, 331, 996 - 998


Northfield’s Surgery of the Central Nervous System 2nd Edition J D Miller, pp 718 - 719; 767 


British Medical Journal   Cauda Equina Syndrome  Clinical Review  BMJ 2009;338:b936 Lavy et al (Nuffield Orthopaedic Centre, Oxford)

© Donald A Campbell 2017