Video - Failure to act on lower back pain

09 April 2019

Video transcript

Dr Marika Davies: The case I'm going to tell you about now involves a motor mechanic whose symptoms were making it difficult for him to go to work. He went to see his GP complaining of constipation and pain in his lower back and down the backs of both legs. 

The examination was normal, so the GP prescribed tramadol and advised him to return if the symptoms didn't improve. The medication helped relieve the symptoms but the back pain persisted. Seven months later, the patient also started having trouble passing urine. He went back to the surgery and the GP arranged an MRI scan of his lumbar spine but did not examine him.

The MRI report suggested that the patient had an arteriovenous malformation in the lower thoracic and upper lumbar region. One month later, the GP sent the report with a letter to the neurosurgical team. It was another six weeks after that that the patient underwent embolisation of the AVM. 

The patient brought a claim against the GP alleging she had failed to carry out an adequate neurological examination, refer the case for a neurosurgical opinion quickly enough and act promptly on the MRI scan results. As a result, he said he
was now suffering from chronic bladder, bowel and sexual dysfunction and ongoing pain and weakness in his legs. 

And, he said, he could no longer walk, drive or go to work. 

Dr Clare Devlin: Medical Protection instructed an expert to comment on the care provided by the GP in a written report on Breach of Duty. The expert considered that the GP should have taken a full history and carried out a neurological examination at both consultations. The expert added that at the second consultation, the urinary problems should have flagged the possibility of a spinal neurological problem. A further criticism was that, in the light of the symptoms, the GP should have discussed the MRI report with the neurosurgeon the same day to enable urgent assessment. 

Dr Marika Davies: The patient was claiming a substantial amount of compensation for loss of earnings and care and accommodation costs. But when he was examined by a neurological expert we instructed, inconsistencies in the medical evidence that supported his claim were found. 

In particular, the loss of power in his legs wasn't as severe as the claim described.

The consultant neurosurgeon provided an expert opinion on the impact of the delays on the patient's condition. The legal term for this is causation, which looks at whether the breaches of duty caused or contributed to any harm experienced by the patient. The expert neurosurgeon commented that even if referral had been made following the second consultation, treatment may not have been provided materially sooner and some of the neurological deficit may have been sustained in any event. Based on expert advice, it was decided to explore settlement because there had been establishment of both breach, and some limited causation.

Dr Vanessa Perrott: Medical Protection recognises that it is often the communication between doctors at the interfaces of care that can cause problems down the line: in this particular case, between the GP and the neurosurgeon. 

To this end, we've developed a framework that can both be used as a diagnostic tool and also to plan interventions that you might want to implement to improve your communication at these interfaces of care. You can find these face to face, or online on Prism, our e-learning system. 

Dr Marika Davies: What can we learn from this case? Spinal vascular malformation poses a risk of neurological compromise. Diagnosing these lesions early and providing timely treatment is critical if patients are to achieve the best neurological outcomes. This was a very high value claim that was reduced by the discrepancies the neurological expert found in the medical evidence. The expert's advice saved Medical Protection, and its members, a considerable sum of money.