Child J, a one-week-old baby girl, was noticed to have a clicking right hip when she was seen by the community midwife. A referral to the orthopaedic clinic was requested and Child J was reviewed by orthopaedic junior doctor, Dr M, three weeks later. Dr M confirmed that there was no relevant family history and examined Child J. Dr M documented that there was no clicking of the hips, and Ortolani and Barlow tests for assessing hip stability were negative. Dr M discharged the baby back to the care of her GP.
During a routine check-up at eight months, Child J’s GP, Dr X, found she had limited rotation of her right leg and immediately arranged for her to have an x-ray. Two days later, following the x-ray, consultant radiologist Dr R described the results as follows: "The left hip is normal. The right hip appears dislocated with associated moderate acetabular dysplasia."
However, due to a failure in the system, the report was simply filed in the hospital record and Dr X did not receive a copy at his surgery.
Three weeks later Child J´s mother brought her in with a minor cold and asked about the x-ray results. Dr X reassured her that he had not heard anything so it was a case of "no news is good news" but he promised to check up on it. Unfortunately, the clinic was very busy and he forgot to look into it.
Child J was reviewed at 16 months, when her mother complained that she "walked funny". Child J had an obvious limp, and on examination her right hip was clearly abnormal. Dr X made an urgent referral to the orthopaedic clinic and a consultant paediatric orthopaedic surgeon, Miss B, confirmed the diagnosis of developmental dysplasia of the hip.
Child J was initially treated with a closed reduction and immobilisation with hip spica, but on follow up at three months, the hip appeared dislocated again. An osteotomy was performed and appropriate immobilisation applied, but unfortunately, months later, the dislocation reoccurred and the dysplasia also seemed to have deteriorated. Child J was referred to a sub-specialist paediatric orthopaedic unit where she was seen by Mr P, a specialist in hip dysplasia. Mr P arranged for Child J to have specialised physical therapy and explained to her parents that it was likely that Child J would require further surgery within the next few years, although it was still too early to predict when and what kind of surgery Child J would need.
Child J’s parents brought a claim against all the doctors involved in the management of their daughter's care. They alleged that Dr M should have requested an x-ray to exclude the dislocation on the initial visit to the orthopaedic clinic. They also alleged that Dr R failed to ensure that the report made it safely to the clinic, and that Dr X had not checked the x-ray but had dismissed their concern. The parents also claimed against the orthopaedic surgeon, Miss B, for failing to treat their daughter's hip appropriately.
Expert opinion
Medical Protection sought expert opinions from a paediatric orthopaedic surgeon and a GP.
The orthopaedic expert considered that Dr M, the junior orthopaedic doctor, had demonstrated an acceptable standard of care. The examination of the baby was normal, with no suggestion of a dislocated hip, and was well-documented. There was no family history to suggest higher risk, therefore an x-ray was not indicated at that time.
The expert GP's opinion on the care provided by Dr X stated that the standard of care was below a reasonable standard, since he failed to follow up the investigation that he had rightly requested. The expert expressed sympathy for Dr X, who had diagnosed the abnormality appropriately, but then failed to follow up on the investigation. If the mother's account of the next consultation was right, he missed a second opportunity to review the x-ray report. All this translated into a long delay of several months in the surgical treatment of Child J's hip.
The orthopaedic expert commented that the surgical treatment by Miss B was in keeping with acceptable practice and that the failure was caused by the advanced state of the dysplasia that made the hip very unstable.
The supportive orthopaedic expert’s report enabled Medical Protection to extricate Dr M and Miss B from this action. The hospital accepted that there had been a clear administrative error that allowed the system to file the report without it being sent to the clinical team for action. The failings in this case meant it was considered indefensible and it was therefore settled for a substantial sum, with the hospital contributing half the costs.
Learning points
- In the New Zealand environment it would be exceedingly rare for there to be a claim of negligence made against the doctors but they may have been vulnerable to a complaint to the HDC.
- Good history-taking and careful documentation of physical examination can make a huge difference if a patient makes a claim against you, which can often be many years after the event.
- When you request a test, you are responsible for ensuring the results are checked and acted upon.
- All systems need a safety net where results are checked so that abnormal results are not missed. It is vital to ensure you have a robust system for acting on tasks that arise from a consultation.
- Poor outcomes are not necessarily the result of negligent medical management. Sometimes poor outcomes are a result of the particular condition. You can help protect yourself from criticism by always ensuring your records outline the rationale for any decision you have taken.