Urgent MRI
13. Miss E says the Trust failed to progress an urgent MRI, requested on 4 September, appropriately. She explained that on 4 September 2018 she took Mr M to an outpatient appointment at the Trust ED and saw Consultant A. She said that she asked for a new scan to be done. One was ordered but this was not done soon enough. The Trust do not dispute the events but say an urgent MRI was ordered.
14. Mr M had long-standing back pain, which was noted to be worsening at the point he presented at the ED. The follow up report from 4 September showed that he had a caudal epidural, which is an injection of pain medication into a narrow opening towards the outer portion of the spine. This had provided some relief but had only lasted for a couple of weeks. Since then, the notes said that symptoms are ‘significantly worse’.
15. Our adviser explained Mr M had pain down the right leg in the right S1 distribution (base of the spine). This means that there was a suggestion a nerve in that area had been impinged. NICE pathways explains that sciatica is caused by compression or irritation of one or more nerve roots in the lumbosacral spine. This can often be caused by a disc prolapse or ‘slipped disc.’ NICE guidelines suggest diagnosis of sciatica when there is pain down one side, along with numbness or tingling. However, they also note that clinicians should be alert for red flags for conditions which overlap with sciatica, and they highlight CES to be one of these.
16. Looking at how CES and sciatica can be differentiated, they describe the symptoms of CES as bilateral sciatica (pain on both sides) and difficulty in moving both legs. Additionally, there is impaired sensation of urinary flow (retention, overflow, or incontinence) and loss of rectal fullness and faecal incontinence. The symptoms recorded on 4 September do not contain any bladder/bowel issues and our adviser confirmed they could not see any indications which would suggest CES at that time.
17. We note Mr M previously had an epidural in July 2018, but his pain got worse again. According to our clinical adviser, the symptoms fit with the assessment of disc prolapse. Our clinical adviser said that there was a need for an urgent MRI, which was arranged. GMC Guidelines (Domain 1 paragraph 15) say doctors should provide a good standard of practice and care and should refer a patient to another practitioner when this serves their needs. The evidence suggests that, on this occasion, Mr M was assessed and referred for an urgent MRI, which was appropriate, according to our adviser. Therefore, we are satisfied that Mr M’s examination on that day was in accordance with the GMC guidelines.
18. However, our adviser confirmed that because of his presenting symptoms of severe back pain and pain radiating to his right leg (which appeared to be worsening), it was reasonable to request an MRI scan at this time to get more information about causes. An urgent MRI was requested. This suggests there may have been a desire to exclude CES. An urgent scan is the highest priority level. An urgent referral without any CES red flags would be done within two weeks. This is supported by a Freedom of Information (FOI) request (in 2017) for this Trust, which says that the target for an urgent referral was less than two weeks.
19. However, the records do not contain any information whether this MRI was actioned. Nevertheless, as we go on to consider, Mr M returned within a couple of days and events overtook this request. According to the advice we received, an urgent MRI was appropriately requested on 4 September 2018. However, due to the events that followed, there was no time for this to be actioned. We therefore have seen no failing in this.
Failed to examine
20. Miss E says Mr M’s health deteriorated, and she took him back to ED on 6 September 2018. She says the doctor did not pay any attention to Mr M and there was no proper examination. She said they were told there was no need for him to be admitted and he was discharged. The Trust said they provided appropriate attention, but his presenting symptoms were not the same as CES, and there was no concern about the decision to discharge.
21. The GMC Guidelines (domain 1 sections 15 and 16) set out what should happen in the approach to assessment. We would expect the Trust to adequately assess the patient, provide suitable advice or treatment, or refer to an appropriate specialist.
22. We note that on this occasion Mr M was triaged and assessed. He was triaged with severe pain and was seen two hours later. The notes say he had severe backache since the morning, was not able to stand, and the pain was radiating to his right leg, as before. They said Mr M reported that the leg felt numb and there was no pins and needles sensation. However, on this occasion, the records also refer to severe weakness in both legs. They noted Mr M changed medication two days earlier (to pregabalin) but that it had had no benefit. However, they also noted that here was no urinary or bowel incontinence. ‘Awaiting MRI.’ The records go on to say, ‘Severe back pain D/W, Dr A advised T&O review. Morphine Ondansetron Ref to T&O’. He was then discharged and left the ED around 45 minutes later.
23. The records therefore suggest he was reviewed, his symptoms reported, and the extent assessed. His recent clinical history and overall context was also considered. We can see they planned to discuss with Trauma and Orthopaedics (T&O), and as such were referring him to an appropriate specialist. This seems to be in line with the GMC Guidelines mentioned above.
24. However, we note that there are no records from T&O. We have asked the Trust to look again and send us any records from T&O from that date, but they have confirmed that they do not have any.
25. Miss E said that they were only seen by a junior doctor at the ED that day. This seems to support the records of a physical review by one person at ED, and specifically no review by T&O despite the intention. While we have no further records from T&O to suggest Mr M was seen, we note letters from Mr M’s GP, provided by Miss E, offer further insight into what happened that day. The GP letter, dated 4 March 2019, states that Mr M spoke with the GP on 6 September 2018. The GP then called T&O and asked that Mr M was seen urgently. However, the orthopaedics registrar on call told the GP that there was no need for Mr M to be seen as there were no concerns, unless he was incontinent, mentioning that he was seen two days ago without this symptom. However, the Trust provided records that Mr M’s case was discussed the following day (7 September 2018) at the morning meeting. The only way that this could have happened is if he was either seen, or his case discussed between ED and T&O on 6 September 2018. It therefore seems likely that Mr M was not physically seen by T&O, but we accept that a discussion between T&O and ED occurred.
26. We therefore considered whether there was a basis to suggest that symptoms of CES were overlooked on this occasion. Looking at the NICE Guidelines (Red flag symptoms and signs) for CES indications include: · bilateral sciatica (on both sides) · Severe or progressive bilateral neurological deficit on the legs, · Difficulty in urinary flow (retention with overflow), · Loss of sensation of rectal fullness/faecal incontinence.
27. His presenting symptoms on the day, as understood by the Trust, were ‘severe backache since this morning… can’t stand… pain radiating to right leg. … severe weakness in both legs’. Miss E also confirmed Mr M was struggling to walk, further supporting the weakness in both legs.
28. Our adviser said the clinical assessment demonstrated normal sensations in both the legs and decreased power in the right leg, due to pain, which would be considered as worsening lower back and sciatic pain, with weakness. However, they added that complaints of bilateral leg weakness would be a red flag and a possible sign of CES, as the weakness was getting worse compared to his last visit two days earlier.
29. Furthermore, Miss E said that they told the Trust about Mr M not passing stools. Miss E has shared with us a conversation between her and Mr M from earlier that day. In that conversation, there is mention of him intending to take laxatives and to speak to his GP about this and pain relief. As such, we do not dispute this symptom but note the records indicated no urinary or bowel incontinence. This suggests it was not understood at this assessment.
30. Miss E described that, at the ED, Mr M was examined for leakage from his rectum. This shows that the Trust did think of CES as a possibility and were considering whether problems with the bowels were present.
31. Overall, we have seen Mr M was complaining of pain and weakness in both legs, and this was understood by the Trust. This is a red flag symptom in the NICE guidelines. Our adviser explained that in cases where there is progression of symptoms, and there is bilateral leg pain (as it is in this case), the CES suspicion index is low. The patient should be sent for an emergency MRI to be done on the day, depending on availability/resources of the Trust.
32. We find a failing as there was a missed opportunity to consider Mr M’s deteriorating symptoms as a red flag and refer him for an emergency MRI. If this had been done, and in light of the results identified on his return, it seems on the balance of probabilities this MRI would have shown signs of CES, and therefore allowed decisions around earlier diagnosis and treatment.
Record keeping
33. Miss E complains the Trust did not have a complete and accurate set of Mr M’s medical records.
34. As we have identified above, there were no records from T&O on 6 September 2018. We asked the Trust to look again, but it confirmed there were no records.
35. According to the GMC guidelines (domain 1, section 19), the Trust should record and keep records in a clear, accurate, and legible way. The clinical records should include relevant clinical findings, the decisions and actions agreed and who made those, as well as what information was given to the patient. They should also include any drugs/treatment provided and the name of the person making the record.
36. As we have seen above, the records do not explain what the interaction between ED and T&O was, or the clinical decision making. Accordingly, this falls below the above standard, and we find a failing in this.
Impact
37. We did not find any failings in the care and treatment Mr M received on 4 September 2018. We appreciate that Miss E says that because of inappropriate care Mr M deteriorated significantly and could not control his bowels. She feels poor complaint handling made her lose faith in the Trust.
38. We note that because of the failure to respond to red flag symptoms on 6 September 2018, Mr M was discharged but returned on 9 September 2018. As we have indicated it seems likely that his presenting symptoms, and findings three days later, meant that CES would have been identified three days earlier. It follows that he would have had the operation earlier. This would have saved him from three to four days of avoidable pain and worry.
39. Furthermore, as a result of the poor record keeping, it is unclear how clinical decisions were made to discharge Mr M on 6 September 2018. This would only add to Miss E’s frustration and distress.