Great Ormond Street Hospital (“GOSH”) for Children NHS Foundation Trust commissioned the Royal College of Surgeons (“RCS”) to review their Paediatric Orthopaedic Service and the care provided by Mr Yaser Jabbar after concerns were raised about his clinical practice in June 2022. Mr Jabbar joined GOSH in 2017 where he practised until 2022 as one of the Consultant Orthopaedic Surgeons within the Limb Lengthening and Reconstruction (“LLR”) Service. He also worked both for the NHS and privately at other London hospitals.
The story has been widely covered in the press and is understandably very emotive and distressing for the families involved.
The redacted RCS report on the paediatric orthopaedics / LLR service at GOSH issued 31 October 2023 is publicly available within the GOSH documents online, and can be found within the documents in this link here. The review raised concerns, among other matters, about the culture within the department, particularly in relation to team working and communication, as well as a lack of a unified, consistent approach to patient pathways and a disconnect between leaders and other health care professionals. The review team considered that, in respect of the LLR service, “the Trust had not been delivering a safe service for patients”.
GOSH states that the RCS recommended a detailed review of approximately 200 of Mr Jabbar’s patients and that the Trust expanded this to include all patients who had clinical contact with him “to ensure thoroughness”. The Trust’s findings were released in a report which was published yesterday entitled, “Patient Recall Findings within the Lower Limb Lengthening and Reconstruction Service, part of the Orthopaedic Surgery Department”.
Within this report, it is stated that the area of medicine being investigated, LLR, is highly specialised. The LLR department of GOSH “assesses and treats some of the most rare and complex conditions affecting arms and/or legs”, and there are often “no established standard approaches” to the management of these conditions either nationally or internationally, with clinical practice often varying between individual specialists. Therefore, there are a limited number of experts nationwide. Initially, three independent Consultant Paediatric Orthopaedic Surgeons with specialist expertise in Limb Reconstruction were recruited to assess the cases, with an additional five being recruited within the last few months to meet the 18-month deadline. Experts met at monthly peer review meetings to discuss complex cases, and took one out of every five cases to these meetings to help ensure a consistent approach. The experts considered the cases by assessing the medical records and imaging available. Where they couldn’t complete an assessment based on the records but felt that there could have been potential harm to a patient, they were able to invite the patient for a consultation and/or request additional imaging.
It was determined that of the 789 patients investigated, 12.4% experienced some harm, and 11.9% suffered harm attributable to Mr Jabbar. For 6.7%, the reviewers were unable to determine whether harm had been caused because insufficient information was available for the experts to be able to make an informed opinion on a potential grading of harm (those gradings being no harm, mild harm, moderate harm and severe harm).
When defining harm, the report refers to a patient safety incident as being defined by NHS England’s Policy guidance as “something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm”. It is stated within the report that “in the context of paediatric limb reconstruction, where staged or repeated surgery is often a necessary and planned part of treatment due to growth and development, further planned procedures are not considered harmful events”. Further, due to the complex nature of the surgery as carried out by Mr Jabbar, it was difficult to establish whether complications arose as a result of poor care or an expected complication. Given that the experts were Orthopaedic Surgeons, and further that it is difficult to assess psychological harm purely from a review of medical notes and documentation, the decision was taken to stop assessing for psychological harm, and thus it is physical harm that is considered within the report.
It is noted that in some cases, the patient records were unclear or incomplete, making it impossible to reach a clear conclusion.
Analysis of the independent expert case reports identified that Mr Jabbar was highly inconsistent in his approach to clinical care.
The areas of Mr Jabbar’s practice considered are summarised in the report as follows:
- Consent;
- History Taking, Examination, Diagnosis and Investigation;
- Case Selection, Decision-Making and Surgical Skill and Technique;
- Identification, Management and Ownership of Complications.
In all four areas, the report sets out standard practice within the UK, findings of the experts and implications for patients. Within these four areas, examples of standard practice were found, along with examples of sub-standard practice.
In area one, it was found that there was “satisfactory documentation of risks and benefits in many cases”, but there were “missing, incomplete or illegible consent forms, overuse of generic language, and insufficient documentation of alternative treatment options”. Further, “there were instances where the procedure undertaken differed from what was originally consented to”. The report goes on to state that in some cases, there was a lack of documented consent around material risks, possible complications and alternative treatments (hereby applying the case of Montgomery v Lanarkshire Health Board [2015] UKSC 11).
In area two, whilst many cases featured a thorough record, some records were brief or incomplete, and a lack of notes or absence of essential details were consistently identified as a concern. Thus, there were instances where surgery proceeded without documented comprehensive assessment. Wrong diagnoses and treatment decisions had been made based solely upon scan or x-ray results without considering the patient as a whole.
In area three, whilst there were examples of surgical techniques aligned to patient needs, there was inconsistent planning, MDT discussion and a tendency to prioritise radiographic findings over clinical symptoms. Some serious problems were found including poor planning, putting implants in the wrong place, making cuts in the bone at the wrong level or using the wrong method, making decisions which didn’t match what was seen in scans during surgery, problems with how frames and pins were used and not involving the wider team when dealing with infections. It was noted that there was insufficient safety netting advice.
In area four, whilst there were examples of prompt recognition and effective management of complications, cases were identified where patients were subject to delayed recognition or management of complications such as compartment syndrome, infection, non-union, malalignment, neurovascular injury with limited onward specialist referral, and infected implants.
The report goes on to consider wider learnings and actions relating to broader concerns raised by the RCS regarding the culture within the department, particularly in relation to team working and communication. The report states that GOSH adopted all 122 recommendations as made by the RCS.
It is acknowledged within the report that patients and families felt unable to raise issues, felt dismissed when raising concerns and worried that they may be seen as troublemakers when raising concerns with Mr Jabbar which could adversely affect their child’s care.
It is stated that patients and families felt “guilt, loss of trust in GOSH, and the level of emotional impact that the review was having on them”. GOSH issue an apology within the report to all patients and families affected.
