Shaw v Stead

In a clinical negligence claim involving acute low back pain, a general practitioner must take an adequate history and conduct an adequate examination to identify cauda equina warning signs. Those signs include altered saddle sensation, bladder or bowel dysfunction, severe or progressive loss of lower-limb power, and bilateral leg pain or sensory disturbance. A patient with such symptoms must be referred to hospital for investigation. If no warning signs are present, the patient must be warned to obtain urgent medical attention if they develop. Where the warning signs were present and a reasonable consultation would have identified them, failure to refer constitutes a breach of duty.

The claimant alleged that the defendant general practitioner negligently failed to identify symptoms of cauda equina syndrome during an out-of-hours consultation on 25 May 2013 and failed to refer her to hospital. Breach of duty was ordered to be tried as a preliminary issue, with causation and quantum to be addressed separately.

The central questions were whether the claimant had relevant red-flag symptoms when examined and, if so, whether those symptoms should have been elicited during a properly conducted consultation.

1. The claim succeeded on the preliminary issue of breach of duty. The claimant bore the burden of proving breach on the balance of probabilities. The applicable principles were those in Bolam v Friern Management Committee [1957] 1 WLR 582 and Bolitho v City and Hackney Health Authority [1998] AC 232.

2. A GP seeing a patient with acute low back pain must take a history and conduct an adequate examination to determine whether red flags are present. The agreed red flags were altered saddle sensation, altered bladder or bowel function, severe or progressive loss of power in the lower limbs, and bilateral leg pain or sensory disturbance. If any red flag is present, referral to hospital for further investigation is required. If none is present, the patient must be warned to seek immediate medical attention if one develops.

3. The question whether red flags existed and the question whether the consultation was adequately conducted had to be assessed together. If red flags were present, the court found that a properly conducted consultation would have identified them. The medical records were important but were not infallible and had to be weighed with the witness and expert evidence.

4. On the evidence, the claimant had experienced a urinary accident after being unable to pass urine, bilateral numbness and tingling, weakness affecting her walking, and severe pain preventing a proper straight-leg-raise examination. She attended in a wheelchair and required assistance onto the examination couch. These matters amounted to red flags requiring referral. The defendant’s record stating “no red flags” did not establish that the necessary symptoms were absent.

5. The red flags were present and were missed. The defendant’s standard of care therefore fell below that reasonably expected of a GP, and he was in breach of duty in failing to refer the claimant to hospital.