Cauda Equina Syndrome and clinical negligence claims in the UK


Anecdotal evidence from annual reviews of claims against the CSP Professional Liability Insurance scheme suggested that mis-diagnosis of Cauda Equine Syndrome (CES) was being seen more frequently with potential for resultant multi-million awards for damages, defence and claimant costs. This retrospective study sought to assess and quantify all claims notified and specifically claims of alleged failure to diagnose Cauda Equina Syndrome, to inform future risk mitigation.


Data of clinical negligence claims notified to the Society┬┤s insurance broker from 2001/02 to 2015/16 was requested and obtained from them. Permission from the CSP CEO and Directors was secured to undertake the study. Claims data was collated by category and analysed. Public liability, employer liability and fitness to practice claims were excluded from the analysis.


A total of 682 claims were notified over the 15 year period. Claims increased from 17 in 2001/02 to 66 in 2015/16. An increase of 388%. A significant increase in claims was seen in 2008/09 compared to the previous year. Subsequent to 2008/09 claims have ranged from 53-78, mean 66.The top 5 categories of claims were "negligent treatment " (n=263), "mis-diagnosis" (n=124), "negligent manual therapy" (n=121), "negligent exercise" (n=56) and "electrotherapy burns" (n=55). The total of the 5 categories equated to 91% of all claims over the period.

The mis-diagnosis category (n=124) comprised 30 cases of undiagnosed fractures, 30 not specified, 10 cauda equina syndrome, 8 tendo-achilles rupture, 7 prolapsed discs and 7 osteosarcomas. The total of these equated to 74% of mis-diagnosis claims. CES claims comprised 8% in this category. Of the 10 claims of CES, 5 were notified in 20115/2016.


Claims against self-employed physiotherapists has increased over the past 15 years. Claims of mis-diagnosis of CES remain very low in number. Although a significant rise in claims notified was seen in 2015/16, there is no evidence of an upward trend. This study was limited to to self employed physiotherapists. The number of cases of mis-diagnosis of CES by NHS physiotherapists is not specified by the NHS Litigation Authority┬┤s (NHSLA) 2016 safety publication which reported 293 claims of incidents of CES between January 2010 and December 2015. Further work is required to understand the prevalence of mis-diagnosis by physiotherapists employed in the NHS.

To mitigate against the significant risk of mis-diagnosis of CES and resultant multi-million pound awards of compensation for clinical negligence, physiotherapists need to learn from litigation studies. Greater awareness raising amongst all musculoskeletal physiotherapists is required of the importance of early symptom recognition of CES by practitioners, and patients who present with back pain and related symptoms.

Funding acknowledgements

This work was not funded.

Additional notes

This work was presented at Physiotherapy UK 2017.