Anonymised Cauda Equina Report

Welcome to AAA Medicolegal Reporting Limited


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


Unit 3, Park Hall Farm, Adderley Road, Cheadle, Staffordshire, ST10 2NJ.

Tel/Fax: 01538 757435

Email:  Bellerophon144@me.com



DRAFT REPORT NOT FOR DISCLOSURE


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



Name:HM


DOB:8th. Never, 1900


Address:


Instructing Solicitors:YZ, Solicitors.


Solicitor Reference:


Our Reference:DAC.DNS.XXXX


Subject of Report:Alleged Medical Negligence  17th. Never, 2222


Documents Reviewed:A Hospital Records


B Hospital Records


C Hospital Records

General Practice Records


Radiology on Disc































Appendix 1:



Graduate of Edinburgh University Medical School.


Full-time NHS Consultant Neurosurgeon for 12 years until 1996,  and thereafter private practice at the Sussex Nuffield Hospital in Brighton and Harley Street, London. He remains in medicolegal practice in Harley Street to date.


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.


Member of Society of Expert Witnesses


Listed in:


Expert Witness Directory

UK Register of expert Witnesses

Expert Witness Website


G.M.C. RegistrationNo. 1333231 (S)


Medical Indemnity Insurers Hiscox Insurance HU PI6 9445073 (9)



Waiting list approximately eight weeks.  Available for consultation at private consulting rooms and hospitals in London, Birmingham,  Manchester, Norwich, and Sheffield.





The report is addressed to the Court by whom the matter is to be heard


This is the first report of Mr D A Campbell, and has been prepared from the supplied records as listed above. I have not examined nor taken a history from the claimant.


I have been supplieed with a paginated bundle of documents and will refer to the page numbers in that bundle where relevant in this report 



1. HISTORY of PRESENT CONDITION


1.1 The history as supplied to me in the form of a letter of instruction is that prior to the events to which this report refers Mr M had suffered a significant head injury followed by right-sided stroke in 19XX. He had subsequently been involved in the motor vehicle traffic accident which resulted in apparently minor injuries and bruising but no significant deterioration in his overall health. 


1.2  The events to which this report refers began on 15 Never 2222, when he developed acute onset of pain in his back unrelieved by simple painkillers. He attended the local  casualty department on three separate occasions and subsequently continued to suffer pain for which he was given anti-inflammatories and physiotherapy was arranged by his GP. By 25 Never 2222 he was re-called to his general practice because of the results of blood tests which had been taken  and was urgently referred on 30 Never 2222 for a hospital opinion from the haematology department. Further investigations as an inpatient in A Hospital including a MRI scan revealed spinal-cord compression by an abscess for which he was referred to the B Hospital and on 16 Never 2222 he underwent decompression surgery with internal fixation of his thoracic spine. Subsequent to that he was transferred to the spinal cord injuries unit at C Hospital where he remained an inpatient until 11 Never 2222. Following this he has been regularly followed up by a variety of specialists but remains significantly disabled.





2. REVIEW OF THE SUPPLIED RECORDS


2.1 General Practice records:

There are hand written records between pagination 106 and 109 covering the dates 1900 to 29 Never 2222. It is noted that the patient had fallen whilst mountaineering  on 5 Never 1900 which led to his neurosurgical treatment for depressed fractures and left him with some mild left sided weakness  but there are no other relevant entries apart from 29 Never 1900 when the road traffic accident described below is also recorded. There are records present in computer-generated format between the dates 21 Never 2222 and 22 Never 2222.  Prior to the events to which my report refers the computer summary of events corresponds to that set out under prior medical history above. In 2222 there is reference to psychological stress after a road traffic accident in which a bed had come off a roof rack on a car in front and smashed through the windscreen. This appears to have settled with appropriate advice and medication. The only other significant health entries are in relation to cardiac problems although the previous head injury in 1900 is recorded in the summary. Specifically there is no history of back problems in the GP notes, and he was clearly not a patient who attended his GP for trivial matters. There is a considerable amount of attached hospital correspondence including summary of his outpatient attendances following the head injury. I shall restrict my detailed comment on such correspondence to salient entries.


2.2 The events to which my report refers are first recorded on 15 Never 2222 when a letter was received by the general practice from the accident department at the A Hospital simply stating that the patient had attended the emergency department. On 17 Never 2222 the patient attended the surgery and was examined by a Dr XXX, who noted tenderness in the mid-to lower thoracic region, and prescribed anti-inflammatory and analgesic medicines and arranged for an x-ray of the spine at hospital. On 21 Never 2222 the patient contacted by telephone Dr. XXX, another GP in the practice, advising that the pain was no better and that he was developing bowel symptoms and it was noted that he had last opened his bowels six days previously, had no sensation and that no x-rays results have been received. 



On 27 Never 2222 a third doctor in the practice, Dr XXX, appears to have seen him in the surgery and noted that the patient had attended the accident department three times with back pain, on each occasion being given painkillers (including tramadol by this stage) and that a plain x-ray had only shown some disk space narrowing. The GP quite correctly notes constipation and  change in bladder function and in particular records normal perianal sensation and anal tone. Quite correctly (s)he states in the note “in light of the suddenness of his pain and urinary symptoms I feel he warrants MRI to rule out Cauda Equina”. This is followed by a line stating that  a template 13031.RTF have been used. (I cannot see any copy of that referral in the bundle with which I have been supplied although there are  copies of the emergency department records from A Hospital between pagination 86 and 91 inclusive and there are then out of hours summaries between pagination 82 and 85 inclusive as well as a single emergency department attendance between pagination 78 and 80 inclusive). On 12 Never 2222 there is a note from a fourth  GP, Dr. XXXX, which simply records that the patients home phone number was on answer machine – it doesn’t explain why the phone call was made nor does there appear to be any further concern expressed. Another entry by Dr XXXXX on the same day notes pain easing only taking ibuprofen and she records that “as pain is easing reassuring but if worsens again and appetite and weight don’t stabilise will need review – did not have MRI in A&E”. Further entries by Dr XXXX and Dr XXXX on 24 Never and 4 Never note that the back pain has been present for seven weeks  and reiterate that there is no weakness, pins and needles, saddle paraesthesiae, bladder or bowel incontinence. It was noted that the patient had had a cough for several weeks. The examination by Dr XXXXX on 4 Never 2222  noted tenderness over the lumbar spine and para-spinal muscles. Further referral was suggested and the patient was “told re warning signs to look out for” although these are not specified. Physiotherapy was arranged and it was recorded that the patient should be reviewed after the results of blood tests were back. The blood tests listed on 4 Never 2222 were all entirely correct for the symptoms, but as will be seen later, do not appear in fact to have been undertaken. Indeed these tests should really have been undertaken earlier. Physiotherapy was arranged on that date. The next relevant entry is 20 Never 



2222 recording an out of hours contact from the patient which would I  presume correspond to pagination 84 and 85. This notes specifically that bowels have not been open for 23 days. It would appear that whoever the “advice Dr” was (? Dr XXXX, or Dr XXX) and did not appear particularly concerned by this history and do not appear to have advised that the patient should be examined – a simple diagnosis of constipation is made with no obvious thought recorded as to the origin of this.  Dr XXX is recorded as having made a telephone call but there are no entries under that section, although  on the same day further telephone call appears to have been undertaken by Dr XXXX, who notes ongoing back pain and no bowel motion for 23 days and noted that the patient had been taking lactulose up to that point but had now taken 8 doses of movicol with some effect  (it is unclear from the notes whether this was all at once or over several days, but the normal dose is two doses up to 3 times per day). Later the same day the patient appears to have attended the surgery where he was seen by Dr XXXX, who notes that a physiotherapist did not feel these symptoms were likely to be sinister and  that the patient was due for blood tests that day (were these the tests referred to in the entry for 4 Never 2222, or further tests -  the only blood tests present for the relevant period  in the GP record are recorded between pagination 26 and 45 as “sample taken” on 23 Nevr 2222, 24 Never 2222 and 25 Never 2222?). Those taken on 23 Never 2222 are said to have been taken at 13:55 hours and the results received on 24 Never 2222, with one exception on pagination 34 with a sample were said to be taken on 23 Never 2222 at 14:01 hours and the report of that investigation for vitamin levels received 26 Never 2222. This single specimen {vitamin D levels} in fact is not of direct relevance to the events to which my report refers. Again the history is noted to have become progressively worse, the patient had lost 2 1/2 stones in weight and there was little relief with medication. It is recorded there was no incontinence but that there was “poor stream and has to push stream sometimes”. It would not appear that the patient was even examined on this occasion nor is there any record that the seriousness of such a deterioration in urinary function was appreciated by the GP. In a separate entry of the same date the same doctor says that rectal examination was not done “as the patient was having blood tests and that rectal examination could be done at a later date if indicated”. Ongoing back and spinal tenderness is noted. There is a note that “bloods today please as above (4 Never 2222) plus please check PSA and review Monday. (23 Never 2222 was a Wednesday and the following Monday therefore 


would have been 28 Never – five days later) I assume this means that the bloods had not been undertaken on the 4th. Never 2222. There is the formal recording that bloods were done in the treatment room on that date.


2.3 On 25 Never 2222 Dr XXXX noted blood results which are classical for chronic infection. After discussion with Dr XXXX, it was decided that the patient should have bloods undertaken for PSA, plasma electrophoresis, uric acid, immunoglobulin levels and urine for Bence Jones protein, following which and only then was an urgent MRI spine to be undertaken “if appropriate”. Following this an attempt was made to telephone the patient and on a mobile phone haemoglobin and that he needed to come in for further investigations for the cause of the back pain. A follow-up appointment for the Monday (28 Never 2222)  was to be rearranged to the Wednesday  (30 Never 2222) “so the results could be available” that is eight days after the blood tests have been taken. On 28 Never Dr XXXX appears to have seen that the blood results simply records was a low vitamin D level – the only action to be taken was to review this the appointment that week that is 30 Never 2222. On the same day  (28. Never 2222) it would appear the patient was seen in the surgery by Dr XXXX with pain in the right flank and she records she was “still awaiting all bloods” and that the “PSA normal”. There is no examination recorded and she records that she would review the patient two days later to decide which department to refer him to when all the bloods were back. On 30 Never abnormal immunoglobulins were noted, yet after discussion with Mr XXXX it was recorded there was “no definite diagnosis yet” and Dr XXXX appears to have continued to believe that this was some form of leukaemia or blood disorder. On 1 Never 2222 the patient in fact telephone to ask whether this could be leukaemia and it would appear that there had been a discussion with a haematologist on-call who said “diagnosis uncertain”. A further set of blood tests were then  to be organised. These were undertaken on 2 Never 2222 and on 3 Never 2222 a further contact was made by the patient with the out of hours service. This would correspond to the out of hours documents on pagination 82 and 83. Here it is recorded that the patient had a blood disorder and was due for a scan the following week. When the patient came off anti-inflammatories on 



the advice of their GP the pain got worse. Under the triage details it was noted that the patient was undergoing investigations for haematological malignancy, and that ESR and CRP were significantly raised. It would appear that the doctor who actually gave this advice in the out of hours service was Dr XXX and says that “patient known to me”. Subsequent entries relate to the patients discharge from hospital after the diagnosis was confirmed.) Never 2222 it was noted that the patient had returned to work reduced to light duties with working from home and – a planned  phased return to work  was not undertaken as the patient simply could not take this up.


2.4 As mentioned above I shall restrict my review of attached hospital correspondence to salient entries. Although the patient did have a head injury in 1969 after falling on a mountain, and had been  assaulted in 1976 these will not have affected his liability to the pathology  to which my report refers. There is nothing in his records to suggest that he was at any unusual risk of infection. The first attendance at B Hospital emergency department  is on pagination 88 to 91. This noted he had attended on  with back pain for a year much worse that day. It would appear the patient was seen by a GP trainee who specifically looked for symptoms of cauda equina compression, did undertake a rectal examination and advised that if the symptoms were no better by the Monday (17 Never 2222) the patient should contact their GP. No investigations of any kind were undertaken, but I would not criticise this at this point (first attendance at an accident department in a middle-aged patient with a one year history of back pain aggravated on that day - even if an x-ray had been taken at that point it is unlikely it would have shown anything relevant). 


2.5 The next attendance at the emergency department of the XXXX Hospital is recorded as 27 Never 2222 (pagination 86 and 87). Here slightly less extensive examination is recorded but it is noted that the patient had been referred by the GP with the sudden onset of back pain two weeks earlier in the absence of trauma. Reflexes are said to have been normal, a rectal examination with normal sensation and tone was recorded; a plain x-ray showed no significant abnormality. The case was discussed with the more senior doctor a Mr BB, who apparently decided that there  


were “no symptoms or signs of cauda equina ”and therefore there was no indication to undertake MRI scanning. Unfortunately we do not know what the referral pro forma referred to in the GP record actually said. More painkillers were given and the patient was advised to return if the patient  had persisting symptoms, develop leg weakness, urinary incontinence or reduced perianal sensation. I would say that if the referral form said that the scan was being requested to exclude Cauda Equina then it would be negligent to refuse it - unfortunately we do not know what that referral said nor on what grounds Mr. BB made the decision that MRI should not be undertaken. Certainly with hindsight it should have been. The third attendance at XXXX Hospital emergency  department is recorded as 5 Never 2222, on pagination 78 to 81. This records that the  patient was being investigated by haematology and was complaining of severe back pain for which morphine was prescribed with some benefit. The words. “? Haematological malignancy” are recorded, and the patient appears to have been admitted to hospital.


2.6 Pagination 76 and 77 are a computer discharge summary from the general medicine department at XXXX Hospital noting a diagnosis of para spinal abscess at T9/10 and recorded that the patient was transferred for spinal surgery on 12 Never 2222. A somewhat unnecessarily rude letter from the physiotherapy department at that same hospital dated 19 Never 2222 noted that the physiotherapist had discharged the patient because of his failure to attend an arranged appointment! A discharge summary from C Park hospital rehabilitation unit in the form of a handwritten discharge letter dated 5 Never 2222 had been sent to the general practice yet no such letter has been supplied in the bundle of records given to me. There is an imaging report of a CT scan of the chest with contrast undertaken on Never 2222 which is said to be compared with scan in Never 2222 and showed some enlargement of the lung lymph nodes which was felt (quite correctly) to be a reflection of the underlying spinal infection. Pagination 67 to 69 is a typed discharge summary from the spinal-cord injuries unit dated 28 Never 2222. This confirms that an MRI scan on 6 Never 2222 shown a paraspinal abscess and the patient was transferred on 12 Never 2222 to C Hospital for appropriate treatment after starting antibiotics. On discharge it was noted that he had regained bowel and bladder continence, had some impaired mobility in walking indoors and outdoors and his walking distance without 



aids was 360 m. Erectile dysfunction is recorded and he was to be trialled on medication. Appropriate antibiotic treatment is referred to in the summary. The infectious diseases department confirm appropriate management on pagination 65 and 66 and pagination at 64 haematologist Dr DDD states in a letter dated 19 Never 2222 saying the patient presented with back pain and leg weakness and that he was unable to find any neurological abnormality on examination. He also says “I have rechecked his protein electrophoresis today and serum free light chain. I do agree with the opinion that this could be a reaction to infection because the band is very small.” There are then letters from the spinal-cord injuries unit outpatient department at C and the orthopaedic unit of C Hospital.  These note the patient to be back at work four days a week and to be able to drive. The  last letter on pagination 59 notes some suggestion of bladder dysfunction and some limited walking without a stick both in and outside his home, but when in crowded areas he still had to use a stick. He also is noted still to have weakness of hip function and quite reasonably it was suggested that automatic car would be more appropriate for him in view of his hip weakness.


3 CONCLUSIONS:


3.1 I believe it best to address the question of breach of duty in three sections. The first relates to the general practice, the second relates to the B Hospital both the haematology department and the general medical department and finally the third relating to B Hospital and C Hospital rehabilitation departments.


3.2 I am concerned that there appeared to be several missing documents from the general practice record as listed in my review of those records above. In particular I note the absence of the hand written discharge summary from C Hospital which is clearly referred to in the record but is not present. Furthermore there are entries in the general practice computer record which are completely blank, yet have the relevant GP’s name beside them. We can see the patient first attended the emergency 


department after that attendance on 15 Never 2222. At that point it would be reasonable to say that when the patient attended on 17 Never 2222, although it is an unusual sight for tenderness (T10 - L3) I would not be critical of the general practitioner attempting treatment with simple painkillers and anti-inflammatories and arranging for plain x-ray of the back. When the patient (who is clearly not a man who attends with frivolous problems at his general practice) telephoned on 21 Never 2222 with significant constipation noted to have started two days prior to the pain the GP makes a note that they wish to wait for an x-ray before undertaking any further action. I would have thought that any reasonable doctor would have said to the patient at that point that if their symptoms were troublesome and not improving prior to the arrival of the x-ray the patient should attend the surgery for further examination and advice. It is clear from the entry on 21 Never 2222 on pagination 10 that the GP felt this was a psychological problem. Nevertheless it might be reasonable in a busy general practice, to suggest this course of action. For this reason I would feel it unlikely that major criticism could be made of the GP on 21 Never 2222. When the patient attended on 27 Never 2222, however, the GP clearly was aware of the potential of cauda equina syndrome and this condition is not one which can simply be left  until  unequivocal clinical signs develop. As soon as the condition is suspected it is mandatory that contact is made with a spinal specialist and that emergency MRI scanning is carried out. It is clear that this doctor must have received training in this problem as the entry specifically refers to bladder disturbance and severe pain. The patient was constipated for two days prior to the onset of pain. (Something entirely unusual for him) there is reference in this entry of 27 Never 2222 to a GP template in .rtf format (Rich Text Format).  This is a document that would be generated on the practice system yet we have not been supplied with a copy of it in the general practice record. For this reason it is essential that this document be obtained as it does not appear to be present in the XXXX Hospital records either. On 4 Never 2222 apart from the fact that there was tenderness over the lower back no record is made of any form of clinical examination of relevance to spinal problems. It is clear that the GP suspected that there could be some form of infectious process going on because they requested a full blood picture (FBP) CRP (C Reactive Protein) a marker for inflammatory change/infection, and ESR (Erythrocyte Sedimentation Rate)  another such marker. They also requested a variety of other tests looking at possible causes for weight loss. There is no record that the patient had to return to have 


these blood test taken yet there is no record anyone in the practice having done this - the only other entry for that date as a letter to physiotherapy. There is then a large gap in the records with the next entry being the reference to the out of hours doctor document (Pagination 84) received by the practice. There is no evidence that this document was reviewed or any decisions made as to whether it should be acted upon. I would not criticise the out of hours service at that point as they did suggest the patient should contact the general practice. On 23 Never 2222 Dr XXX  acted correctly in advising the patient by  telephone to come in for reassessment, but when they did so Dr XXXX clearly records a deterioration in pain, and new disturbance of bladder function. This mandated an immediate telephone call from the practice to their local accident department at the very least stressing that this was a patient where they suspected incipient cauda equina compression, where they had asked for an MRI scan already which was not undertaken on the advice of a doctor in the accident department and where the patient was deteriorating. I would have thought it only reasonable for Dr XXXX to have telephoned the XXXX hospital as an emergency and to have looked back at the earlier attendances in relation to these symptoms over the preceding four weeks, and noticed that the blood tests that were felt essential on 4 Never 2222 had not been undertaken. Again these tests  would be something that would be expected to be undertaken by the emergency Department on the re-referral. The most damaging and inexplicable entries present are on pagination 7.  On 25 Never 2222 Dr XXXX notes “raised CRP, raised ESR, low haemoglobin…….”. These results were present in the general practice record and are shown on pagination  34 to 35 inclusive. Of particular relevance is the fact that on pagination 36 the white cell count is noted to be 7.5 with 72% neutrophils and although these results are said to be within normal limits they are all on the high side of normal. The ESR was grossly elevated at 129 with the upper limit of normal being 15, and the CRP on the same set of results pagination 41 was 119 with an upper  limit of 5. There is also a report of a plain x-ray  on pagination 45 which is reported in effect is normal – I have not seen this nor any other radially radiology imaging, and it is essential that I am supplied with such imaging on a disc. There is no record the patient’s temperature being taken, but a  swinging temperature is seen (classical sign of the presence of a surgical abscess) on the patient’s nursing charts to the XXXX Hospital on 5 Never 2222 (although instead of a proper chart the nurses have simply filled in numbers under varying times which makes the interpretation of such 


charts extremely difficult unless the graph is filled in properly as it should be). I make this criticism of the general practice not as a specialist, but any medical student faced with results of this type would be expected to say that the commonest explanation for such results is infection, and when combined with someone with severe unusual back pain a spinal abscess. This makes the comment on pagination 7 by Dr XXXX during a telephone conversation that it was acceptable to wait till “Wednesday next week” so the results could be available completely unacceptable. We know from the laboratory computer printout that the reports were in fact received in relation to all the critical tests on 24 Never 2222 having been issued to the general practice on 23 Never 2222. (Pagination 35 to 44). There is no explanation why Dr XXXX did not look at these computer-generated results when asking the patient to come back for a variety of other blood tests which, to be honest, were completely irrelevant. It is clear that Dr XXXX was fixated on this being some form of multiple myeloma or leukaemia to the exclusion of all other diagnoses. When the patient again saw Dr XXXX on 28 Never 2222 it is clear that she had not looked at the blood results which were available to her, and had not made a decision as to which speciality to refer the patient and therefore what the differential diagnosis was. Without this no logical treatment plan can be proposed. Again this I am afraid to say is simply negligent, and  even worse was her statement that after discussion with Mr. XXXX (s)he had clearly become fixated on a blood malignancy diagnosis for which (s)he referred the patient to a haematologist. Again there is no copy of this referral letter in the GP notes and I cannot find a copy of it in the XXXX hospital notes. It would appear that discussion took place the following day by telephone between between Dr. XXXXX and the on-call haematology doctor a Dr YYYYY, who suggested a variety of screening tests looking for  myeloma. Again there is no record of this telephone conference in either XXXX Hospital notes nor GP Records,  nor do we know what degree of experience Dr YYYYYY has or had, or even what his/her grade is. There are then simply records noting that the patient had been admitted to hospital.


3.3 I have been supplied with records from the XXXX Hospital in relation to this admission. In addition are other entries of attendances for unrelated matters have been interleaved for some reason between relevant pages. I shall only comment 


that the  2222 records are difficult therefore to follow in logical sequence and would also say that the method of filling in the temperature chart by the nursing staff  is completely unacceptable and not under any circumstances appropriate – numbers are simply recorded on the chart instead of a graph meaning the swinging temperature failed to be recorded in a way which would make it obvious anyone looking at the chart. I also note that the patient’s temperature had dropped down to below 36° on several occasions – this is far below normal (37.3) yet none of the nurses seem to have brought this to the attention of any of the medical staff – it may simply have been incompetent temperature taking or a faulty instrument but for any normal adult in a hospital to have a temperature as low as 35.4 centigrade is extremely abnormal. I have on my own copy entered the appropriate temperatures and it is clear that there was a swinging temperature chart absolutely diagnostic of pus in an abscess. (Pagination 65) I also note with interest that under the nursing records, a large number of which are simply blank, on pagination 61 in spite of the temperature of the patient being recorded as 35.4° the nurses state that “there is no concern about controlling the patient’s temperature”. Temperature continues to be recorded in an incorrect form in several of the NEWS (National Early Warning Scale) nursing charts throughout the admission. It is also noteworthy that these same nursing records contain a screening tool for sepsis which on pagination 52 specifically states that if the temperature is less than 36° or the heart rate is greater than 90 bpm this should immediately result in the diagnosis of sepsis and appropriate treatment within an hour. These values are certainly recorded pagination 67 on 6 Never 2222 yet no action has been taken!  The  recommendation in that document states that such values should result immediate prescription of oxygen, intravenous fluids, blood cultures, lactate infusion, intravenous antibiotics and urine output measurement. Intravenous antibiotics were not in fact prescribed until 8 Never 2222 at 12:00 hours, and the fluid balance recording is frankly absent or inadequate prior to that date. There are  “multidisciplinary progress notes” between pagination 21 and 30. These begin on 8 Never 2222 when it is noted intravenous antibiotic have been started, they contain no proper clinical examination summaries but do notice that the patient had been transferred from (presumably Ward) NN at 19:33 hours with a diagnosis of discitis and paraspinal abscess. A ward round at10:15 hours on 9 Never 2222 recorded discussion with the spinal surgery team who advised antibiotics but not to undertake a biopsy. (this is completely unacceptable - how would you know which 


antibiotics were appropriate?  This could be TB or bacterial and require different antibiotics depending on the infecting organism which can only be identified at this stage by needle biopsy or surgery) It was noted that a CT scan was awaited and by 9 Never 2222 at 14:27 hours it was said that the abscess was said to be getting smaller. Discussion was undertaken with a Dr WWWW, a locum consultant spinal surgeon who advised no intervention but repeating MRI scans every couple of weeks and to re-contact should there be any change in the neurological status. On 12 Never 2222 the patient was noted to have weak legs, to have fallen,  to be struggling to pass urine and an urgent MRI scan was to be undertaken straightaway.   By 15:05 hours  on 12 Never 2222 it was noted that anal tone was reduced and it was noted the spinal team were refusing to take the patient until a further scan had been undertaken (why?? - they knew there was an abscess, the position was getting worse and the earlier decompression is undertaken the better the outlook for recovery of function). At 17:26 hours it is clearly recorded that the spinal team had “once again” been informed that the symptoms were suggestive of developing cord compression. At 18:26 hours the spinal team were again contacted but still refused to accept the patient and said they would would call back. The medical registrar then contacted the neurosurgical team as well who advised that this had to be dealt with by the spinal team. Only when the neurosurgeon spoke to spinal registrar arrangements made the patient’s transfer. (Pagination 24)


3.4 There are also hand written records in relation to the patient’s admission to XXXX Hospital. Pagination 104 appears to be the admission note from 5 Never 2222 at 20:45 hours noting the patient had been admitted with back pain from suspected underlying malignancy. There is then a complaint that the notes have been filed in the wrong order. Pagination 96 to 99 appears to be the medical assessment unit admission and contains both nursing records and medical records from 5 Never 2222. These note the history and record at 12:40 hours that the haematology doctor on call a Dr. DDDDD specifically advised that this was not the picture of the myeloma, and advised an emergency CT scan. What can only be described as an extremely limited neurological assessment which completely fails to record sensation at any level is present but advises  the correct investigations namely CT scan and 



MRI scan which were then undertaken. (Pagination 96 to 99) There are  more extensive handwritten records between pagination 100 and 101. These begin with a note at 10:00 hours on 6 Never 2222 noting that the radiologist advised orthopaedic input and further investigations. A doctor whose bleep number is  666 notes that contact was made with the spinal unit and  that they would “get back”. A phone call from the spinal unit registrar is noted  who advised this would be reasonable advice. There then appears which seems to have handwriting and on the same page – perhaps this was self duplicating paper, but even holding it up to a mirror I can only read at the very top of the page advice for appropriate intravenous antibiotics timed at 16:30 I believe it is essential that proper copies of these pages be obtained and transcribed. Considerable handwritten notes following pagination 106 to104 in relation to appropriate investigations which seems certainly at the foot of page 102 to suggest that the attempted biopsy had not produced sufficient tissue to give guidance. It was then noted at the foot of the page after discussion with Dr O’Kane that contact should be made with the Royal Victoria Hospital asking them to undertake the biopsy. It is clear that this reasonable request  was refused and the XXXX Hospital were also advised that antibiotics should not be started that evening but should wait until there was further discussion the next day.  (This is completely unacceptable and negligent advice) On pagination 103 a doctor with a bleep number 357 expresses understandable frustration about repeated attempts to discuss the matter with the spinal and orthopaedic doctors at the Royal Victoria Hospital had been frustrated by the fact that they could not get through. The doctor specific records “I feel we will be unlikely to achieve answers from an appropriate person out of hours”. The doctor then decided to continue with antibiotics and attempt to make contact the following morning with the spinal unit. At 23:45 hours on 6 Never 2222 more contact was attempted with the spinal team and they could not get through the switchboard to the doctor on call and the spinal ward had no way of contacting them. It is specifically recorded in pagination 105 that there was no way of contacting the spinal registrar out of hours. At the foot of that page it is noted a discussion with a junior would then be further undertaken with a more senior doctor and that it “may well be the morning before we get a definite answer”. The following morning a diagnosis of spinal abscess is confirmed and it was noted at 12:10 hours on 7 Never 2222 spinal team at BBB Hospital had discussed this with Dr XYZ  and that they would not “currently” be transferring the patient. Multiple attempts at contacting a variety of doctors 



in the spinal unit  are recorded on pagination  109 along with handwritten recording of the blood results. By 8 Never 2222 it was noted on pagination 111 that the ward had been unable to find anyone to give a time for  the biopsy and that they were trying to discuss this again with the spinal unit at the BBB Hospital and that  blood culture results were available. In view of rising CRP by 12 midday was noted that the on call  orthopaedic doctor at the BBB Hospital knew nothing about the patient but would liaise with the spinal team in theatre. On pagination 112 it is recorded that he discussed the matter with his registrar and states unequivocally  it was advised that there was no need for the spinal team to be involved but they could be contacted again if there was a deterioration. There is then a note on pagination 113 that there seemed to be some difficulty in discussing the matter with Dr XYZ and that another spinal consultant’s advice was to be sought. 19:40 hours on 12 Never 2222 it was noted that the patient was to be transferred as an emergency to the Royal Victoria Hospital. I should also note on pagination 149 to 151 although it probably relates to earlier hearing problems the reproductions are completely illegible. There are  subsequent laboratory results for Never 2222 and Never 2222 which are not of any direct relevance except to show that the underlying blood abnormalities were due to infection. Also there are notes in relation to concern about cardiac function as a complication of the abscess. These lie outside my area of expertise to comment upon. Pagination 165 is a hand written transfer note from the nursing staff noting the intravenous flucloxacillin had been given but there is no date or signature  on this. Pagination 166 to 175 and again computer clinical records relating to the admission on 5 Never 2222 in the evening noting that pain and constipation, no clinical examination is recorded and there is no sensory chart. Difficulty with obtaining a biopsy and the difficulty in communication with B Hospital are recorded on pagination 168 and 169 along with the advice from Dr XYZ dated 9 Never 2222 and timed at 15:06 hours not to undertake any transfer or management and only to contact him again should there be a deterioration in the patient’s condition. I have to say this is completely unacceptable. Pagination 76 to 79 appear to be multiple duplicates of the medical admission form. Pagination 31 appears to be a general medicine referral from the general medical unit or accident unit at XXXX Hospital to the consultant radiologists at C Hospital  dated 8 Never 2222 repeating the results of the scan which in essence showed abnormal tissue compressing the spinal canal in the middle of 


the thoracic spine and states that there is evidence of discitis at  T9/T10, yet states that there is no abscess present. Pagination 32 has the telling phrase “Liaison has been made with the spinal team at B Hospital  on several occasions, the lead consultant is Mr (sic) XYZ. This letter states that the patient was off antibiotics,  and blood results on 7 Never 2222 are attached. (Again these are quite clearly consistent with the commonest likely diagnosis of spinal abscess). There is a handwritten incompletely copied transfer letter on pagination 69 which is difficult to read but states that the initial MRI scan did show a paraspinal abscess and that this had been discussed with the spinal team who declined to operate. It was noted that “this morning” (there is no date on this letter) the patient developed urinary retention and leg weakness. The MRI scan showed worsening compression of the spinal cord by abscess  and oedema. It is also noted that it was a different spinal consultant a Mr CCCCC (a neurosurgeon)  who accepted the patient.


3.5 There are radiology reports from 6 Never 2222 of CT scanning and MRI scanning of the spine and abdomen. These showed soft tissue mass with further enlargement of the abscess and bone destruction at T9/10. Some concern was expressed about the aorta being slightly dilated – this would not be directly related to this problem but what is of importance, however, is the phrase on the report of 6 Never 2222 on pagination 71 “Paraspinal abscess formation is identified” and on pagination 178 the report for a scan on 9 Never 2222 which has  under “indicationsfor scan”  “had MRI (6/5/2222)  T9/10 discitis and para-spinal abscess formation” On pagination 177 is a report of MRI scanning of the spine dated 12 Never 2222 noting progression of the changes already described on 6 Never 2222.There is no record in the supplied documents of the referral letter to haematology nor of the nature of the discussion with Dr ABC nor what documentation that Dr ABC  was supplied with.


3.6 In terms of both management and follow-up, I can summarise my assessment of C Hospital by saying that their record keeping  is of the highest standard, and the clinical decisions were made in accordance with current practice and in an appropriate and timely fashion. I do not believe any blame can attached to to C 



Hospital. I do not believe the Court would be assisted by going through these records in detail as I have no criticism of that  hospital.


3.7 In relation to the B Hospital records, however, I am, however, concerned about the decision and advice given by Dr XYZ to the unit at XXXX Hospital. It is widely accepted that where medical treatment of a spinal abscess is to be undertaken that must be undertaken on the basis of aspiration of the abscess  in order to identify the infective agent and determine the appropriate antibiotic treatment. (For example in this case the organism eventually proved to be Staphylococcus Aureus, but the described discitis and bone destruction is also highly suggestive of Tuberculosis which would require entirely different antibiotics, and the only way to differentiate between the two is by obtaining a sample of pus). This initially could  be done initially percutaneously as a needle aspiration, but if there is any suggestion of neurological deterioration emergency decompressive surgery is mandated. Indeed standard United Kingdom practice is that where spinal abscess is suspected emergency aspiration of the pus is required and if there is the slightest doubt of any deterioration in the patient’s neurology or recollection of the abscess surgery must be undertaken without further delay. I appreciate that Dr XYZ  was a locum, and is of another nationality and does not have English as a first language, but acting in such a  manner that would never be felt acceptable in that country.  The fact that no biopsy had been undertaken, the radiologist had reported the presence of a paraspinal abscess with bone destruction on 6 Never 2222   and that Dr XYZ advised his junior doctor not to accept the patient either for a scan or a biopsy before another scan had been repeated is simply unacceptable in UK practice. There is obviously some  interaction between the neurosurgical unit in the B Hospital and the spinal unit, and it is reasonable to infer that the neurosurgical unit made this course of action clear to the spinal unit resulting in the eventual acceptance of the patient as an emergency by that unit. There is nothing in these records to show any recording of discussion by the various doctors involved up to the point where transfer occurred. Once the patient had been transferred under the care of Mr. WXY, Consultant Neurosurgeon,   the management was as might be expected impeccable the patient’s current position is probably best assessed by the ASIA chart completed on 10 Never 2222 which noted persisting sensory disturbance to light touch and pinprick throughout the spine 


from T2 downwards and involving the perineum. I reiterate I do not have any records of his neurological assessment subsequent to that date in detail and have not examined the patient myself. I would say for the avoidance of any doubt that once the patient was managed by Mr WXY and the rehabilitation no criticism would apply to any part of his management.


4 CONCLUSIONS:


4.1 Although I would defer to the opinion of a general practice expert, I believe Dr XXXX to have been negligent in failing to ensure appropriate laboratory results were obtained in a timely manner, failing to keep an open mind on differential diagnosis and thereby becoming fixated on the possibility of myeloma to the exclusion of the correct diagnosis of spinal abscess. There is no evidence that (s)he drew up a list of differential diagnoses and then proceeded in a logical fashion to exclude or confirm these – had investigations give the impression that (s)he was fixated on the diagnosis of myeloma to the exclusion of all else. (S)he did not ensure that the blood tests requested on 4 Never 2004 were undertaken, did not enquire there these tests results were after a few days (even if the diagnosis were malignant disease the patient must have been not only in severe pain but very worried about what was going on and should ethically have been kept informed of the progress of the tests and (s)he should have chased up the results within a few days of 4 Never 2222). (S)he has not made a reasonable differential diagnosis on the basis of the blood tests which were eventually  undertaken on 4 Never 2004, and instead simply undertook a further set of tests to confirm the presence of malignant disease rather than questioning what else could give rise to the results (s)he had available particularly in correlation with the restricted clinical examination (s)he had undertaken. Having clearly mentioned potential Cauda Equina compression in his/her initial referral to casualty (a condition which is an absolute spinal emergency no matter whether due to abscess or malignancy) (s)he should have pressed the accident department for the scan which (s)he clearly knew was necessary. Any reasonable GP at the very least would have contacted casualty that day  to ask what the outcome of the scan was, and if told that a junior doctor had said the scan was not necessary would then at the very least have 


spoken to the on call consultant to check if that was really appropriate. Had the patient been referred in an appropriate and timely fashion in Never 2222 it is indeed likely that following aspiration of the pus, surgery could have been avoided altogether and the condition treated with the appropriate antibiotics, the collapse of the vertebral bodies leading to the necessity for mechanical stabilisation would have been avoided and even if surgery have proved necessary it would have been undertaken nearly 6 weeks earlier than it eventually was. This delay will have given rise to avoidable neurological damage.


4.2 I am also concerned by the clear lack of emergency cover provided by B Hospital  spinal unit  in this case. It is completely unacceptable to say that a spinal unit doctor can only be contacted during working hours. Spinal surgery must provide emergency service  24 hours a day. It is clear that hospital policy has  prevented the neurosurgical unit providing that emergency cover. Even a patient who  presents with rapidly progressing spinal cord compression from malignancy  requires emergency decompression to prevent the establishment of irreversible paraplegia prior to radiotherapy - this  is absolutely essential. 

I have no criticism whatever of Mr WXY who acted in an appropriate and timely manner throughout. I have to say, however, that Dr XYZ’s behaviour is completely unacceptable and is not remotely in line with acceptable spinal practice in the United Kingdom in the management of spinal compression whether from abscess or other causes. It shows a complete lack of appreciation of what was being told to him/her, and a complete lack of urgency in what was manifestly an emergency problem. It was not the fault of the XXXX Hospital that transfer was delayed by nearly a week in spite of repeated telephone calls by a variety of doctors to the B Hospital (recorded throughout the XXXX Hospital medical notes) but purely the result of the intransigence of the spinal unit at B Hospital. Whilst the deterioration in that week was only worst on the last couple of days when incontinence and paraplegia developed, and Mr WXY’s skill has minimised damage, there will have been avoidable deterioration in the week between the diagnosis being obvious on scanning on 6 Never 2222 in the XXXX Hospital and the eventual appropriate surgical decompression. Had transfer occurred on 6 or even 7 Never, the degree of neurological damage would have been significantly less, the loss of badder control and paraplegia would have been 



avoided and the outcome and recovery would have been more complete and more rapid for the patient.




I, Donald Angus Campbell, declare that:

1 I understand that my primary duty in furnishing written reports and giving evidence is to assist the Court and that this takes priority over any duties which I owe  to the party or parties by whom I have been engaged or by whom I have been paid or am liable to be paid. I confirm that I have complied with and will continue to comply with this duty.


2 I have endeavoured in my reports and in my opinions to be accurate and to have covered all relevant issues concerning the matters stated, which I have been asked to address, and the opinions expressed represent my true and complete professional opinion.


3 I have endeavoured to include in my report those matters of which I have knowledge and of which I have been made aware which might adversely affect the validity of my opinion.


4 I have indicated the source of all information that I have used.



5 I have, where possible, formed an independent view of matters suggested to me by others including my instructing lawyers and their client, and I have so disclosed in my report.



6 I will notify those instructing me immediately and confirm in writing if, for any reason, my existing report or opinion requires any correction or qualification.


7 I understand that:


(a) my report, subject to any corrections before swearing as to its correctness, will form the evidence which I will give under oath or affirmation.


(b) I Never be cross-examined on my report by a cross examiner assisted by an expert.


(c) I am likely to be the subject of public adverse criticism by the judge if the Court concludes that I have not taken reasonable care in trying to meet the standards set out above.


8 I confirm that I have not entered into any arrangement whereby the amount of payment of my fees, charges or expenses is in any way dependent upon the outcome of this case.









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

Consultant Neurosurgeon


5 Never 2222


References:


(1) Mackenzie A R et al Spinal epidural abscess: the importance of early diagnosis and treatment

Journal of Neurology, Neurosurgery & Psychiatry 1998;65:209-212. 

 This has excellent summary of condition and factors affecting recovery


(2)   http://www.londonspine.co.uk/indexc45e.html?page_id=637


(3). This weblink explains clearly the nature of the problem and accept management practice in UK centres - it is current and confirms the opinions in Ref (1) and specifically mentions the problem of TB


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


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


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


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


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


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

© Donald A Campbell 2019