By Robert Dransfield, Partner, Penningtons Manches Cooper
The National Suspected Cauda Equina Syndrome (CES) Pathway published by Getting It Right First Time (GIRFT) in 2023 was intended to address long-standing delays in diagnosis and treatment of this critical condition.
Since its introduction, a number of UK clinicians have published audits and service reviews examining how the pathway operates in practice.
This article, by specialist cauda equina claims solicitor Robert Dransfield, considers that emerging literature and asks whether GIRFT has delivered meaningful improvement in patient care or whether familiar systemic challenges persist.
Introduction and the cost of delayed diagnosis
Much has been written about cauda equina syndrome (CES), both clinically and legally, and it is a condition that has attracted sustained attention because of the severe and irreversible harm that can result when diagnosis or treatment is delayed.
In practice, that harm frequently includes permanent neurological damage, sexual dysfunction, and lifelong bowel and bladder impairment, with profound consequences for patients and their families.
I would note that many clinical talks and research papers in this area lead with the financial costs. In the UK, litigation costs related to CES are estimated to exceed £186 million per decade.
The report by the Healthcare Safety Investigation Branch (HSSIB) noted that the cost of CES-related litigation claims for the 2014/15 to 2015/16 period alone was £68 million [1].
Average damages per claim were estimated at approximately £810,000 between 2013/14 and 2017/18. Those figures are now a decade old and from my experience the current average value of claims is at least £1.5 million.
Most of the papers referenced below put the average age of claimants at around 50. With a life expectancy into the mid-80s, this creates more than 30 years to account for, covering loss of earnings, therapies, equipment, accommodation and care.
As a medical negligence solicitor, I have witnessed a significant number of cases where things have gone wrong, ending in life-changing injuries.
When GIRFT published the CES pathway [2], I was hopeful that there was a commitment to change the system and prevent CES injuries. The pathway that emerged was ultimately disappointing when compared to the recommendations in the 2022 HSSIB investigation into the timely detection and treatment of CES.
Anecdotally, I am seeing the same issues arising now as before the introduction of GIRFT, along with some new ones that appear to be unintended consequences of the implementation of the pathway. An article marking Cauda Equina Day by Ray Ross and Naveed Yasin captures many of these issues from a medico-legal perspective [3].
After a piece on the GIRFT website caught my eye, I decided to take a more detailed, evidence-led look at the published literature.
There have been quite a few papers published from clinicians around the country reflecting on local programmes and the issues they have faced.
The GIRFT website is notable mainly for how little has been published in the past three years. The only paper that is referenced is a piece celebrating a fall in national imaging referrals and emergency department attendances as a result of the GIRFT pathway [4].
As a patient advocate rather than an emergency department triage nurse or radiology manager, this is concerning, especially when viewed in light of the rest of the recent literature.
From my perspective, reductions in attendance or scanning are of limited reassurance in the absence of published patient outcome data.
The paper does assume that GIRFT has been adopted nationally yet research from 2025 suggests that only 58 per cent of primary care clinicians were aware of the GIRFT pathway [5].
What follows draws on a review of themes arising from various clinical papers and local service evaluations published since 2023.
I am grateful to the Royal Society of Medicine for access to its physical and online library resources which have been invaluable during this process.
How did we get to the current GIRFT guidelines?
To address the longstanding problems surrounding the diagnosis of CES and the associated cost to the NHS, the GIRFT programme published the National Suspected Cauda Equina Syndrome Pathway in February 2023 [2].
The development of this pathway followed detailed discussion of the patient journey, notably driven by the 2022 HSSIB investigation [1].
The HSSIB report examined reference cases where patients repeatedly sought help for worsening back and pelvic pain, only to experience significant and in some cases indefensible delays in receiving magnetic resonance imaging (MRI) and specialist surgical care [1].
In response, the GIRFT pathway established a clear clinical target, mandating that patients presenting with red flag symptoms require an ’emergency MRI as soon as possible, certainly within four hours of request’ [2].
It is interesting that Rao and Chitgopkar reference a secondary benchmark of 24 hours from admission to scan report [6].
Many of the HSSIB recommendations, such as 24-hour scanning, were presumably considered to be unaffordable. GIRFT instead seems to have attempted to tackle the problem by reducing the number of negative attendances rather than increasing resource.
A consistent theme emerging from the various papers is that there are a number of problems with the treatment pathway which GIRFT has been unable to solve.
Has anything changed?
Identifying CES on the basis of clinical signs alone remains difficult.
The classic red flag symptoms – such as bilateral sciatica, saddle anaesthesia, and changes in urinary function – are open to subjective interpretation and overlap significantly with less serious causes of back pain [7].
Because missing the diagnosis has such serious consequences, clinical caution drives a high number of MRI requests: over 80 per cent of urgent MRIs for suspected CES ultimately show no cauda equina compression.
It is interesting that the authors of the various papers, despite GIRFT, did not all apply the same criteria to red flags.
If neurosurgeons two to three years after the pathway publication are using their own criteria, were the original GIRFT criteria fit for purpose?
There are also practical issues with inconsistent medical records.
Some papers note that it is not uncommon for emergency department records to reflect that no abnormality was detected, even where subsequent evidence suggests otherwise.
From my own experience, retracing steps with clients often reveals WhatsApp, social media and even video content that completely contradicts the findings recorded in the emergency department notes.
I have also seen red flags clearly recorded in triage and clerking notes that are apparently entirely absent in examinations undertaken hours later.
With my medico-legal hat on, I would argue that where clerking notes, contemporaneous messaging and video evidence document saddle numbness and difficulty going to the toilet, it is unlikely a judge will prefer a four line emergency department note recording ‘no abnormality detected’.
Triage can be complicated by resource pressures and variable clinical clerking. Sometimes, patients presenting with red flag symptoms are directed to general practitioner (GP) led out-of-hours services in the minor department rather than being evaluated straightaway by an emergency department doctor with direct access to emergency imaging [8].
This introduces an extra layer of delay, preventing early contact with a senior doctor able to question the radiology gatekeepers, often requiring the patient to be re-referred back to the main emergency department.
When a wait to see the GP is often over four hours, it is not surprising that many of my clients are easily persuaded go home.
I have noticed a hierarchy operating during CES triage: GPs being discounted by ED departments, and ED doctors in turn discounted by tertiary referral doctors who will only act if they can see a scan.
The four-hour GIRFT target for MRI scans has not been met with additional resources. It seems the plan was to cut the number of patients attending and create headroom that way.
A primary reason is that many district general hospitals simply do not have the radiographer staffing required to operate an MRI scanner 24 hours a day, seven days a week.
The ENTICE national audit previously revealed that the median time to MRI at referring hospitals without a dedicated spinal unit was 13.2 to 13.3 hours [9]. In some areas, 24 hours has been set as an acceptable outcome measure.
Communication between local referring hospitals and specialist spinal units can also be subject to breakdowns, particularly during out-of-hours shifts.
That is why as a patient, you do not want to be waiting for an out of hours scan.
It is doubly frustrating to bounce between a minor injury unit and emergency department, then wait for a bladder scan. I have a number of clients who, despite arriving in the morning, missed the last scanning slot.
The HSSIB report detailed a severe case where an urgent electronic referral to a regional specialist spinal centre was sent at 19:12 but went completely unnoticed for hours [1].
The referral was only discovered because a neurosurgery registrar coincidentally logged into the computer system at 22:00.
It is common to see cases where decisions are put off, or district hospitals are told there are no beds, or that a local MRI is required prior to discussion. Access to scanning is something that still plagues the system.
When an MRI confirms that a patient has CES, there is often a contentious wait for surgery.
The Society of British Neurological Surgeons (SBNS) and the British Association of Spine Surgeons (BASS) provide clear guidance: ‘Nothing is to be gained by delaying surgery and potentially much to be lost. Decompressive surgery should be undertaken at the earliest opportunity’ [10].
In practice, however, many specialist centres have policies against operating overnight for non-life-threatening conditions, recognising that the performance of surgical teams can be suboptimal at night [1].
In the HSSIB reference event, a patient who was transferred as an emergency in the early hours of the morning waited over 10 hours to receive surgery, largely due to a lack of available radiographers for the operating theatre X-ray equipment [1].
The medico-legal standard at the moment seems to be ‘first on the morning list’. Letters of response frequently assert this position but with no analysis of whether there was capacity to undertake overnight surgery or whether that might have been justified.
First on the list can drift to early afternoon, waiting until after the morning shift ward round before anything is actioned.
GIRFT seems to have added a further hurdle, the bladder scan. The pathway does not suggest it rules out CES but rather it should accelerate treatment.
Waiting an additional four hours with saddle parasthesia and urinary problems for a bladder scan seems self defeating.
I am aware of two studies suggesting that more than 200ml residue is an indicator of serious problems, but this does not negate the need for timely escalation.
Of the clients I have represented who spent four to ten hours in the emergency department waiting for an initial assessment and then experienced a further delay before a bladder scan, none had a fluid balance chart.
I remain unsure how many patients trapped in an emergency department with severe back pain are consuming litres of water in tiny paper cups in anticipation of their bladder scan.
Summary
It is not all doom and gloom and I would encourage anyone interested in this subject to read beyond the ‘legal briefings’ and high level summaries.
The literature is really insightful; clinicians on the ground and not just medical negligence lawyers are clearly alive to the issues, even the 42 per cent that are not aware of GIRFT.
Local solutions are being created and papers published reflecting specific constraints, although it is a shame that the majority are not on the GIRFT website.
In part 2 of this article, I will consider the implications of initiatives trialled in Luton [11], Medway, Salisbury and Nottingham for potential national solutions and set out my own view as to what should now be advocated for. That includes whether, five years on, GIRFT itself requires a formal review – and whether it is time to consider what ‘getting it right second time’ might look like for patients with suspected cauda equina syndrome.
Bibliography
- Health Services Safety Investigations Body (HSSIB). Timely detection and treatment of cauda equina syndrome. Investigation Report, 2022.
- Getting It Right First Time (GIRFT). Spinal surgery: national suspected cauda equina syndrome (CES) pathway, 2023.
- Ross, R, Yasin, N. Hidden mechanisms of failure in the management of spinal conditions with neurology focusing on cauda equina syndrome.
- GIRFT guidance reduces cauda equina syndrome (CES) related admissions without negatively impacting diagnosis. Neuroradiol J, 2025.
- Cauda equina syndrome: a survey of guideline utilisation in primary care in England. Musculoskeletal care, 2025.
- Rao, E, & Chitgopkar, S. Cauda equina syndrome – most frequent referral diagnosis to a tertiary spinal centre: a retrospective study. Journal of Spine Surgery, 2025.
- Najjar, E, Khan, S, Masarwa, R, & Grevitt, MP. The suspected cauda equina syndrome score (SuCESS): Development and validation of a clinical triage tool. The Bone & Joint Journal, 2026.
- Conte, A, Lingham, A, Nagulendran, S, et al. Improving the suspected cauda equina syndrome pathway at a district general hospital: a quality improvement project. BMJ Open Quality, 2025.
- Fountain, DM, Davies, SCL, Woodfield, J, et al. Evaluation of nationwide referral pathways, investigation and treatment of suspected cauda equina syndrome in the United Kingdom. British Journal of Neurosurgery, 2019.
- Society of British Neurological Surgeons (SBNS) and British Association of Spine Surgeons (BASS). Standards of care for investigation and management of cauda equina syndrome (CES), 2018.
- Naik, A, Abbas, G, Roche, O, et al. Luton cauda equina syndrome pathway: a pragmatic approach to achieve a national target of time to scan in UK district general hospitals. Bone & Joint Open, 2026.
Robert Dransfield, Partner, Penningtons Manches Cooper
E: robert.dransfied@penningtonslaw.com
Hope House Children’s Hospice partners with Slater and Gordon
