Toddler’s Re-dislocated Hip Not Identified For Months

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a DHB and orthopaedic surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in their care of a toddler following surgery.

The toddler was diagnosed with developmental dysplasia of the hip after he began walking with a limp. The orthopaedic surgeon subsequently performed corrective surgery and the toddler had a cast applied. Following the surgery, the toddler attended appointments with the orthopaedic surgeon on multiple occasions to check his progress and change his cast.

While the orthopaedic surgeon checked the toddler’s hip with an X-ray each time his cast was changed, he did not recognise the toddler’s hip had re-dislocated. He did not identify the re-dislocation for several months, despite the radiologists who reviewed the X-rays noting there were changes to the hip and that orthopaedic review was required.

The Deputy Commissioner found that the orthopaedic surgeon failed to perform a CT scan after surgery, failed to interpret several X-rays correctly and failed to review several radiologists’ reports that identified the dislocated hip. The surgeon also failed to place sufficient weight on the concerns of the toddler’s parents.

"This report highlights the importance of clinicians interpreting X-rays correctly, reading radiologists’ reports and investigating concerning clinical features," Mr Allan said.

"All of these factors should have prompted the surgeon to investigate the toddler’s hip further."

The Deputy Commissioner found that the DHB had no policy in place requiring a CT scan following surgery for developmental dysplasia of the hip, and no reliable system to check than orthopaedic surgeon had read and approved a radiologist’s report.

Mr Allan recommended that the DHB undertake as an audit of developmental dysplasia of the hip surgery undertaken on children over the last 12 months, and ensure that all children have had a CT scan and have been seen in a consultant clinic until stability is confirmed.

He was satisfied that the orthopaedic surgeon has taken appropriate steps to improve his practice since these events and that both the surgeon and the DHB had provided a written apology to the toddler’s family.

The full report on case 19HDC01077 is available on the HDC website.

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