Lessons learned: A lawyer’s perspective on the new CES Pathway

In a recent article, Simon Elliman explored the new treatment pathway for Cauda Equina Syndrome (‘CES’), delivered as part of the NHS’s ‘Getting in Right First Time’ initiative. There appears to be a consensus that the new CES pathway is a positive development, and that it will improve practise, speed up diagnoses, and create a much-needed consistency across hospital Trusts in terms of identifying and treating CES.

He notes, for instance, that the very comprehensive list of red flag symptoms listed by the pathway is to be welcomed, since it is more comprehensive than the list contained in the NICE Guidance or Oxford Handbook of Emergency Medicine.

Sadly, most of my clients suffered their injury prior to the drafting and implementation of the pathway. In hindsight, a number of these clients could have avoided their injury if the pathway had been in place. For example, one client was told to look out for urinary incontinence but interpreted this as ‘not being able to go’. The new guidance elaborates on the urinary symptoms to look out for and includes not knowing when your bladder is full or empty and loss of sensation when urinating. It is clear from my client’s statement that, had this expanded list of red flags formed part of the return advice, he would have attended A&E earlier and, per the pathway, would have undergone a neurological examination and MRI scan much sooner.

Whilst it is important to recognise that the pathway is a significant step forward, there are still lessons to be learned, and it is my view that the pathway will evolve over time in consultation with clinicians (particularly urologists) and with the help of organisations such as the Cauda Equina Champions Charity. For example, the pathway requires that a patient must have CES symptoms arising within the last two weeks in order to obtain an emergency referral. As noted by Claire Thornber of the Cauda Equina Champions Charity, there is a concern that defining the need for emergency treatment by recent onset of symptoms (i.e. within two weeks) is dangerous. A survey of the charity’s membership suggests that the onset of bladder symptoms is often more gradual and sometimes takes place over months not weeks. I share these concerns and have seen this in my own practice. In one of my cases, the Claimant developed urinary symptoms over a two-month period and would not have met the requirement for an urgent referral until it was too late to prevent CESR. I would like to see the two-week criterion re-examined as it may lead to patients who need emergency treatment being wrongly triaged into the less urgent pathway.

MRI scanning and the CES Pathway

The pathway also recommends that an MRI scan should be performed as soon as possible “and certainly within four hours of request to radiology”. This recommendation is good in theory, but doesn’t account for fluctuations in local, staffing, resourcing and funding – which in turn determines the availability of MRI scanning facilities and appointments. One of my clients was referred by his GP for an MRI after reporting recent onset bi-lateral sciatica (a red flag for CES). However, the wait for the NHS appointment was several weeks. Ultimately, he asked and paid for a private MRI scan, which took place within a few days and confirmed CE compression. Still not ideal, but significantly quicker than the NHS appointment and might have saved him from complete CES had it not been for later substandard care.

Notwithstanding the later substandard care, it is concerning that a Claimant presenting with CES red flags would have waited several weeks for an MRI scan if he did not have the means to pay privately. What happens to those patients who cannot afford a private MRI scan?

Conclusion

Overall, I am delighted that the pathway has been put in place and only wish that it had happened sooner. I do have some lingering concerns about the two week onset criteria and the continued pressures on the NHS in respect of resourcing and staffing, but I am confident that the pathway will be refined and improved over time.