Summary
C complained about the actions taken by their GP practice in relation to reports of worsening back pain and related symptoms. C called the practice and reported severe lower back pain (on a history of sciatica - back and leg pain caused by irritation or compression of the nerve that runs from the lower back down the back of each leg), pins and needles in their feet, a reduction in their ability to walk, and tightness in their calves. When asked, C did not report any bladder or bowel incontinence or loss of sensation and therefore was advised to call back for an appointment after the weekend as there were no available appointments.
On progression of C’s symptoms over the following ten days, they were offered an appointment, and later referred to orthopaedics and diagnosed with cauda equina syndrome (a condition where the spinal nerves in the lower back become severely compressed). C underwent surgery for this condition.
C complained about the lack of action taken when first reporting the symptoms, that when C’s longstanding symptoms of sciatica progressed to include bilaterial pins and needles, tightening of the calves and reduced mobility, these symptoms were not acted upon and no urgent referral was made. C was concerned that the significance of evolving red flag symptoms were not fully recognised.
We took independent, clinical advice from a GP adviser. We found that based on relevant guidelines, worsening bilateral neurological symptoms and difficulty walking should have prompted urgent clinical assessment. We found that it would have been reasonable to direct C for urgent same-day assessment, either within the practice or via A&E.
There were also failures in record keeping. The contemporaneous clinical records for the day in question were minimal and did not reflect the severity of the symptoms described by C, any triage discussion with a clinician, or any safety-netting advice provided. There was no evidence in the records to support the practice’s account that appropriate screening questions were asked or that adequate advice was given. Finally, while the practice had carried out a Significant Event Analysis, this contained inaccuracies and did not identify key issues.
While, when C contacted the practice in the following days, C was given appropriate advice, we considered that this did not negate the missed opportunity when the symptoms were first suggestive of potential neurological compromise. We therefore upheld the complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for failing to take reasonable action in relation to their reports of worsening back pain and related symptoms. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: All clinicians should be aware of the red flags for cauda equina syndrome including bilateral neurological deficit of the legs and difficulty walking and the appropriate action to take when these symptoms are reported.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202510650 as a PDF (28.28 KB) Updated: September 23, 2026