William Audland QC and Isaac Hogarth of 12 King’s Bench Walk, instructed by Hugh Johnson of Stewarts successfully represented the claimant (“C”) in his claim against University College London Hospitals NHS Trust (“D”), weeks before the start of a trial on liability, achieving a settlement of £4.5 million at a video Joint Settlement Meeting (JSM).
The claim arose from a delay in treating spinal cord compression secondary to spontaneous spinal epidural haematoma (SEH).
C was a 37-year-old man, who experienced the sudden onset of chest pain late at night, and attended D’s Emergency Department, arriving just after midnight. On triage, he was noted to have a half hour history of chest pain, difficulty breathing and numbness in his shoulder blades.
At 01:22, believing that he was going to die, C recorded a video on his mobile phone to his wife and children. He recorded a second video at 01:38, in which he said that his back was now hurting, he was unable to feel his feet, he had pins and needles and was in pain.
At this point, he was reviewed by Dr T, a middle grade doctor. Dr T formed the view that C was suffering from a panic attack, possibly with gastritis, reflux or gallstones. He provided medication to address panic attack and gastritis, but did not perform a full neurological examination.
At around 02:50, C attempted to get up as he needed to pass urine. Upon attempting to mobilise, it was apparent that he was unable to stand, and he collapsed to the floor. He was lifted into a wheelchair by the nurse and taken to the toilet. He was unable to pass urine, although he felt the urge to do so.
He was then taken for a chest x-ray, and thereafter was transferred to the majors area of the emergency department. An examination documented at 03:45 recorded that C was now paralysed from the chest downwards with loss of sensation.
Dr T referred to the medical registrar, who attended at 04:30 and documented differential diagnoses with a plan as follows:
“Imp: ?spinal infarct (but ↓reflexes & ↓vibration)
? periodic paralysis (but [normal] K+)
? thoracic dissection extending to spinal vessels
Plan: 1) CT angio aortic & spine +/- MRI
2) stroke opinion
3) a/w [await] bloods inc CA, TFTs
4) FVC serial 1º [hourly Forced Vital Capacity testing]
At 04:45, C was transferred to resus.
An entry timed at 05:30 documented a review by the stroke registrar, who noted a complete loss of power around T6, with no lower limb power, but normal upper limb neurology. The clinical impression was of likely spinal cord stroke +/- aortic dissection. Urgent CT angiogram of the aorta was arranged. The plan was also for urgent MRI of the cervical/ thoracic spine.
The CT aortogram of the spine took place at 06:03 and ruled out aortic dissection. The report strongly recommended MRI.
It was ultimately agreed between the experts that once aortic dissection had been ruled out, urgent MRI was needed to investigate the possibility of a compressive pathology.
The hospital did not have overnight MRI facilities on site, although D’s written protocol in respect of back pain provided that in the case of suspected neurosurgical emergencies “including progressive or severe neurological deficit”, the patient should be transferred to the nearby Queen Square Hospital, which was a part of the same trust. It emerged that none of the junior doctors involved in C’s care was aware of that policy.
In the event, C did not undergo MRI until around 12:00, and the neurosurgeons were not first contacted until during that scan.
There was then a delay in arranging ambulance transfer to Queen Square, as the referring physician failed to convey the fact of known cord compression. The transfer should have been ‘critical’ (within minutes) rather than ‘immediate’ (within two hours).
C ultimately arrived at Queen Square at 17:44 and went to theatre at 18:15. At the point of his surgery, C was a complete Frankel A paraplegic.
Decompression was achieved.
C thereafter underwent a prolonged period of rehabilitation.
As a result of his spinal cord injury, C is a T3 Frankel B paraplegic.
The parties’ pleaded cases
C’s case was that decompression ought to have been achieved within six hours of onset of paraplegia, and that this would on the balance of probabilities have led to a very favourable outcome, with C being a Frankel E (normal motor and sensory function).
C’s alternative case was that even if decompression had been achieved within 12 hours of onset, it was likely on the balance of probabilities that he would have been a good walking Frankel D (some sensory loss only).
Despite a highly critical Serious Incident Report, D made only limited admissions on breach of duty, and denied causation entirely.
The claim was listed for a trial on the preliminary issue of liability (including causation), where it was anticipated that there would be expert evidence from experts in emergency medicine, acute medicine, neurology and neurosurgery.
Whilst there were significant issues between the parties on breach and factual causation, the key battleground was medical causation.
D’s experts were of the opinion that due to the speed of onset, the spinal level of the lesion (thoracic) and C’s condition at the point of decompression (which on any view would have been Frankel A), that it was not likely that earlier decompression, even within six hours of onset, would have led to a better outcome.
C’s legal team and neurosurgical expert undertook detailed reviews of the literature and attempted to demonstrate that D’s experts were wrong in their understanding.
On close analysis, what the literature showed was that:
- Even where there is a complete lesion at the thoracic level, that does not contraindicate a favourable outcome;
- That the largest studies which include helpful meta-analyses of large datasets (which include mixed cohorts of subjects with complete and incomplete lesions) demonstrate that outcome is generally favourable where there is decompression within 12 hours of onset;
- However, caution needs to be exercised when relying on the large meta-analyses, as the recorded data often lacks sufficient detail on certain key factors (including, for instance, the timing of decompression);
- When considering the case reports in respect of which full data is recorded, it was possible to demonstrate that on the balance of probabilities, even where there were complete lesions at the thoracic level, if decompression occurred within 12 hours, the majority of subjects improved to at least walking Frankel D.
The JSM took place via Microsoft Teams.
Although both parties initially made offers on a liability-only basis (on the basis of a percentage of a specific outcome), full quantum offers were ultimately made, which led to resolution of the claim.
The claim was settled for a lump sum of £4.5 million.
12 King’s Bench Walk
1st October 2020.