Decision report 201202725

Summary

Miss C had a history of occasional minor back pain over a number of years, and was diagnosed with sciatica and a prolapsed disc. In November 2011, Miss C developed pain in her lower back and pelvis, which made walking very painful. The pain moved to her right hip, leg and buttock and she began to experience numbness and muscle weakness. In early January 2012, the pain moved again to her lower back and upper left leg. The pain was severe and affected her mobility. Miss C phoned NHS 24, having not been able to contact her own GP. Miss C's GP was asked to visit her at home. He prescribed pain medication and advised her to monitor her condition and to contact NHS 24 again should the pain worsen when the practice was closed. Miss C contacted NHS 24 again late that night. It was suggested that she attend an accident and emergency unit, but due to the pain she experienced when sitting, standing or walking, she did not feel able to do so. NHS 24 then arranged for an out-of-hours (OOH) GP to conduct a consultation by phone. The OOH GP concluded that Miss C's condition was improving and that she likely had a urinary infection. She was told that she should continue to self-monitor overnight. Miss C's condition deteriorated further the following day and, after another call to NHS 24, she was admitted to hospital where she underwent emergency surgery. She was diagnosed with cauda equina syndrome, where a lesion, or prolapsed disc, presses on the nerves at the base of the spinal cord, causing pain, numbness, weakness and/or urinary disturbance or faecal incontinence.

Miss C raised a number of concerns about the OOH GP's assessment of her condition and his failure to visit her at home or to arrange an ambulance to take her to hospital that night. She was left with persistent numbness after her surgery and felt that, had the OOH GP recognised the red-flag symptoms (symptoms that are especially likely to indicate a particular serious illness) of cauda equina, and arranged for her to be admitted to hospital earlier, this might have been prevented.

We found that Miss C had described recognised red-flag symptoms of cauda equina to NHS 24 and the OOH GP. These included numbness in the area between the legs and urinary problems. We accepted independent medical advice that these should have prompted a home visit from the OOH GP. Although we acknowledged that Miss C's symptoms and mobility appeared to be improving between the time of her discussions with NHS 24 and the OOH GP, this is not uncommon for patients with cauda equina and the fact that red-flag symptoms had been described should have been the primary consideration. We considered that, by failing to carry out a home visit, the OOH GP did not put himself in a position to properly diagnose or rule out cauda equina syndrome.

Recommendations

We recommended that the board:

• share our findings with the OOH GP and consider whether additional training should be provided to him on the identification of, and response to, red flag symptoms; and
• apologise to Miss C for failing to provide a home visit.