Jarman v Brighton and Sussex University Hospitals NHS Trust
[2021] EWHC 323 (QB)
Judgment delivered by Jason Coppel QC, sitting as a Deputy Judge of the High Court, on 18 February 2021.
The issue
The central question was whether the claimant’s clinical presentation on 3 March 2015 mandated emergency magnetic resonance imaging (MRI) for suspected cauda equina syndrome, and whether the subsequent delay in decompression surgery resulted in additional, compensable neurological injury.
Facts
The claimant, a primary school teacher, sustained a back injury at work in February 2015 and later developed subjective symptoms suggestive of cauda equina syndrome, including altered perineal sensation and urinary and bowel changes. On 3 March 2015, her general practitioner directed her to the emergency department following symptom progression. An orthopaedic registrar conducted a comprehensive history and targeted examination. While the claimant reported subjective red-flag symptoms, objective findings revealed preserved perianal sensation, normal anal tone, no lower-limb motor deficit, and a negligible post-void residual bladder volume. Concluding that cauda equina syndrome was not clinically present, the registrar diagnosed a lumbar disc prolapse, scheduled an MRI for ongoing radicular symptoms, and provided safety-netting advice. An MRI performed on 18 March confirmed a prolapsed disc compressing the cauda equina. Following report review on 20 March, decompression surgery was undertaken on 21 March, leaving the claimant with permanent neurological deficits.
Claim and Decision
The claimant alleged that the Trust breached its duty by failing to arrange emergency or significantly earlier MRI on 3 March, arguing that earlier imaging and decompression would have improved her neurological prognosis. The Trust defended the registrar’s clinical assessment and denied both breach and causation. The court dismissed the claim. It found that the orthopaedic registrar’s decision not to order immediate emergency imaging fell within acceptable clinical practice, as the objective examination did not support a diagnosis of cauda equina syndrome. Notably, the claimant’s own orthopaedic expert described the examination as unusually thorough. On causation, the court was unconvinced that the claimant’s neurological condition materially deteriorated during the disputed interval or that earlier surgery would probably have altered the outcome.
Legal Principle
The urgency of MRI for suspected cauda equina syndrome must be determined by the complete contemporaneous clinical presentation rather than isolated subjective symptoms. While red-flag complaints warrant careful evaluation, they do not automatically mandate emergency imaging when a competent examination yields reassuring objective findings. The court assesses clinical decisions based on information available at the time, meaning later imaging confirmation of compression does not retrospectively render earlier triage negligent. Crucially, breach and causation remain distinct. Demonstrating that earlier imaging and surgery were possible does not establish liability unless the claimant proves that the delay probably caused additional injury.
Clinical Significance
Cauda equina syndrome remains a time-critical condition requiring urgent investigation and specialist management when reasonably suspected. Jarman does not advocate routine delay in the presence of meaningful red flags. Instead, it underscores a fact-specific, clinical assessment approach that weighs the history, reported symptoms, objective examination, bladder assessment, clinician reasoning, assigned imaging urgency, and provided safety-netting. The judgment should not be misinterpreted as establishing a blanket rule that preserved anal tone, intact perianal sensation, or normal bladder scans definitively exclude cauda equina compression. These findings are simply components of a holistic clinical evaluation.
Radiological Significance
Although primarily a case concerning clinical triage rather than radiological interpretation, the imaging played a central role in the causation analysis. Key questions included what an earlier MRI would likely have revealed, whether the degree of compression warranted urgent surgery, whether imaging demonstrated interval deterioration, and whether earlier decompression would probably have improved the neurological outcome. The case clarifies the boundary between clinical referral and radiological assessment. The examining clinician determines whether emergency investigation is clinically justified, while radiologists or protocol vets must ensure that requested urgency aligns with the supplied clinical information. Material discrepancies between stated red flags and deferred imaging priorities should prompt clarification or escalation through established local pathways.
Practical Guidance
For clinicians, documenting the full cauda equina assessment is essential. Records should capture symptom onset and progression, perineal sensory changes, urinary and bowel dysfunction, bilateral or progressive neurological signs, lower-limb power, reflexes, and sensation, perianal tone where examined, bladder assessment results, the working diagnosis, the rationale for imaging priority, and safety-netting advice. Documentation does not replace competent care but provides critical evidence of the clinical reasoning that guided management decisions.
For radiologists, referrals suggesting possible cauda equina syndrome require careful review of the clinical indication against the requested priority. When material red flags are present but deferred or routine imaging is requested, clarification or escalation is warranted. Clinical suspicion should not be independently downgraded without adequate information and adherence to local protocols.
For legal professionals, the analysis must rigorously separate the adequacy of the history and examination, the rationale for emergency imaging, administrative scheduling, the timing of MRI and surgery under competent care, the anticipated imaging findings, and the probable impact of earlier intervention on neurological outcome. The subsequent MRI diagnosis does not establish breach. Contemporaneous records, witness testimony, and clinical findings are paramount. Causation demands a specific counterfactual timeline, as the mere possibility of earlier investigation is insufficient to prove liability.
Evidence to Obtain
A thorough medicolegal review typically requires primary care and physiotherapy records, emergency department notes, orthopaedic and spinal assessment documentation, bladder-scan results, the original MRI request and assigned priority, booking and scheduling logs, the initial MRI images and report, operative notes and surgical findings, postoperative neurological evaluations, local pathways for cauda equina and emergency MRI, and expert evidence spanning clinical specialties, neuroradiology, and neurological causation and prognosis.
Relationship with Other Authorities
Jarman should not be conflated with Darnley v Croydon Health Services NHS Trust [2018] UKSC 50, which addressed misleading information regarding emergency department waiting times. Its focus remains strictly on whether the clinical presentation necessitated emergency MRI and whether the subsequent delay caused additional harm, rather than on radiographic adequacy or general triage misinformation.
Conclusion
Jarman is a fact-specific decision reaffirming that medicolegal liability requires clear proof that earlier imaging and surgical intervention would probably have improved the patient’s neurological outcome. Clinical urgency must be guided by comprehensive, contemporaneous assessment rather than automatic escalation for subjective symptoms alone.
Educational case commentary only. It is not legal advice, medical advice or a substitute for the judgment. The publication date above is the date of this commentary, the judgment was delivered on 18 February 2021.