Cauda equina syndrome negligence: common failures in diagnosis and treatment

Cauda Equina Syndrome (CES) is a serious, rare neurological condition caused by compression of the cauda equina nerve roots at the base of the spinal cord. When not diagnosed or treated in a timely fashion, the consequences can be life‑long and devastating — bladder, bowel, sexual dysfunction; mobility impairment; chronic pain; psychological injury.

Key features or “red flag” symptoms include things like urinary dysfunction sometimes progressing to retention or incontinence, bowel dysfunction, saddle anaesthesia (numbness in the genitals / buttocks), lower limb weakness or sensory loss.

Once suspected, the accepted standard is emergency MRI imaging and urgent decompression surgery, because delays can lead to permanent damage.

Common failings in CES negligence cases

In our experience, the most common failures in CES cases are:

Missed or unrecognised red flag symptoms
Where a patient presents to a GP or to Accident and Emergency complaining of lower back pain together with “red flag” symptoms and these are not recognised, a patient may be diagnosed with mechanical back pain or sciatica, and discharged home without further investigations being carried out.

If Cauda Equina Syndrome is suspected, an urgent referral for an MRI scan is required. This should be carried out in four hours.

Inadequate clinical examination or documentation
We have seen cases where there has been a failure to test for objective signs of CES and ask detailed questions about bladder and bowel function. Our clients often report being asked about urinary incontinence but not about dysfunction – symptoms like straining to pass urine or requiring the application of abdominal pressure to begin passing urine. With a report of no incontinence the medical professional is sometimes (wrongly) reassured this is not CES and does not refer on for further investigations.

Poor notes can make it difficult to prove when symptoms began or how severe they were, so detailed evidence from a client is key.

Delays in imaging
MRI is the standard diagnostic tool. An X-ray is not sufficient and may be ordered in place of an MRI scan, which is poor care.

Delays can also happen if radiologists downgrade the urgency of a scan, a lack of out‑of‑hours MRI service, or a delay in getting a patient to the scanner.

Imaging can be delayed if an MRI scan is not requested on an urgent basis. Getting it Right First Time (2023) sets a standard for imaging in a case of suspected CES of 4 hours from the onset of symptoms or the report of CES red flags.

Delays in referral or surgery
Even once diagnosis is reasonably suspected, a delay in transferring to spinal or neurosurgical specialists and a subsequent delay in then performing decompression surgery can lead to irreversible damage.

Communication failures; A failure to offer “safety netting” advice
There can be communication issues between clinicians, between departments (A&E, orthopaedics, radiology, neurosurgery), and with the patient. We have seen cases where incomplete information has been provided to a neurosurgery department asked to review a possible CES patient, without the full medical history. There can be delays whilst further information is obtained, and sometimes further examinations are necessary, like bladder scans. This can then delay a decision for surgery. 

A common issue in cases involving cauda equina is patients not being told how serious some symptoms are or when to return or what red flags for CES are.

A failure to give appropriate safety netting advice about when to seek urgent medical attention for red flags can result in delays in a patient returning to seek a medical review.

Our CES cases

You can read more about the CES cases we have been involved in here:

£1,330,000 settlement for patient with cauda equina syndrome (CES)

Liability admission for delayed MRI in cauda equina red flag case

Implications / Recommendations

From the themes, the following repeatedly come up as ways to reduce risk of clinical negligence in CES cases:

• Clear and well‑publicised clinical pathways for suspected CES (e.g. “national suspected CES pathway”) to standardise what should happen and when need to be adhered to.
• Education and training for frontline clinicians (GPs, A&E, physiotherapists) about red flag symptoms, urgency of imaging, and proper assessment.
• Ensuring MRI imaging is accessible rapidly, including out of hours, and that there is agreed process to escalate urgent spinal MRI when needed.
• Prompt surgical referral / decision-making once diagnosis is made.
• Good documentation at every stage (history, examination, decision points, referrals).
• Supportive culture where errors or near‑misses are analysed and learned from, rather than punished, to prevent recurrence.
• Good communication to patients, including explaining risks, signs to watch for, and encouraging patients to return if symptoms worsen.

Conclusion

Cauda Equina Syndrome remains one of the significant conditions in clinical negligence litigation due to its devastating consequences and the narrow window for effective intervention. Despite clear clinical guidance, many claims arise from missed or ignored red flag symptoms, delays in imaging or referral, and failures in communication or documentation.

For healthcare professionals, the legal risk is closely tied to how well they recognise and respond to early signs of CES. For healthcare organisations, the priority must be ensuring timely access to MRI, specialist input, and a clear, well-communicated pathway for suspected cases.

Ultimately, avoiding CES-related negligence claims requires a combination of clinical vigilance, robust systems, and patient-centred care. When systems fail, the costs—both human and financial—are profound.

Our downloadable guides

A helpful guide on Cauda Equina Syndrome

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