Can you claim when a GP doesn’t warn you about the risks of cauda equina syndrome?

The “red flag” symptoms of which patients with sciatica should be warned are as follows:

• Loss of feeling and/or pins and needles between the inner thighs or genitals.
• Numbness in or around the back passage or buttocks.
• Altered feeling when using toilet paper to wipe.
• Increasing difficulty when trying to urinate.
• Increase difficulty when trying to stop or control the flow of urine.
• Loss of sensation when passing urine
• Leaking urine or recent need to use pads
• Not knowing when the bladder is either full or empty
• Inability to stop a bowel movement or leaking
• Loss of sensation when passing a bowel motion
• Change in ability to achieve an erection or ejaculate
• Loss of sensation in genitals during sexual intercourse

How urgent is cauda equina syndrome?

Cauda equina syndrome is a medical emergency. Any of the above symptoms may be an indicator that there is compression of the nerves in the cauda equina at the base of the spine, which regulate urinary and bowel function, as well as sexual function. If the nerves are sufficiently compressed over a period of time, permanent damage will be done to those vital functions. Timely intervention by surgery to decompress the nerves may result in those functions being preserved, or at least a comparatively improved outcome for the patient.

In order to ensure that there is early detection of CES, and prompt and effective intervention, it is crucial that the patient is aware of the early warning signs, so that they can attend their GP, or the Emergency Department, as soon as such signs or symptoms develop. Safety netting advice about how to recognise signs of impending CES, and what to do in that eventuality is accordingly essential.

Probably most patients with sciatica will consult their General Practitioner (GP) initially, so GPs are often in a situation when they should be providing safety netting advice about cauda equina “red flags”. An interesting question is whether there is an obligation to provide the same advice on each occasion that a patient presents with sciatica, even if the advice has been given before.

How should a GP act upon those warning signs?

The answer is that a GP cannot assume that the advice has been given before by another practitioner, and should not assume that a patient will remember previous advice in any event; there is an ongoing duty to warn. A GP should always record when such advice is given; a shorthand such as “red flag advice given” or “CES safety netting advice given” would suffice.

The same considerations apply when a patient attends the Emergency Department with sciatica, or a physiotherapist, osteopath or chiropractor; there is an obligation to provide CES safety netting advice, and to records that this has been done.

In a recent case successfully pursued by RWK Goodman, the claimant attended his GP complaining of sciatica. Questions were asked by the GP about whether “red flag” symptoms had been suffered, but those questions were not given context.

The GP, once a medical negligence claim for cauda equina injury was brought, maintained that he had given appropriate safety netting advice, but the claimant denied that he had received any such advice.

The GP recorded in his notes: “Sciatica playing up no red flags advice also.” These words were the source of considerable debate during the case. Did they mean that “red flag” advice had been given, or that no red flags were present, but that more general advice was given? The GP gave two advice leaflets to the claimant but neither of them were about sciatica, or contained “red flag” advice about CES, which lent weight to the second interpretation.

The same day, the claimant developed a change of sensation when urinating, but did not act upon this or seek advice, as he was not aware of the significance of this symptom. The following day he noticed some difficulty in starting urination, and some sensory change in his buttocks. Again he did not seek medical advice about these symptoms, because he did not understand their significance. On the next day he awoke with more severe symptoms and telephoned NHS 111. He was advised to attend the Emergency Department, which he did, leading to his admission, diagnosis with CES and eventually to surgery to decompress the nerves in the cauda equina area.

Unfortunately the surgery was too late, and the claimant was left with permanent bladder and bowel dysfunction as well as sexual dysfunction. He subsequently took medical retirement from his employment as he felt unable to continue his work, which was client-facing, with his symptoms of urinary and bowel incontinence.

The claim was pursued almost to trial, but eventually a settlement was agreed two months prior to trial, with the claimant receiving £400,000 in damages. The case would have turned upon a judge’s analysis of the cogency of the evidence of the claimant and the defendant GP; essentially the more convincing witness at trial would have won the case.

When will a claim for failure to provide ‘safety-netting’ advice succeed?

There are a number of required elements for such a claim to succeed.

First, the claimant must give convincing evidence that no adequate advice was given. This may be rebutted by a good note to the contrary made by the GP or other clinician.

Secondly, the lack of advice must have affected the claimant’s subsequent behaviour; in other words, had the advice been given he would have acted differently.

Thirdly, the difference in behaviour must have affected the outcome in terms of the permanence or severity of the claimant’s cauda equina syndrome.

In order to make a claim for negligence against your GP, the first course of action is to contact a specialist medical negligence solicitor. They will assess the merits of your case, and guide you through the process towards receiving the compensation you deserve.