Page 6 - PIC-Magazine-Issue-26

Release of the Report Concerning
Patients of Mr Jabbar at Great Ormond
Street Hospital for Children
reat Ormond Street Hospital
(“GOSH”) for Children
that the area of medicine
NHS Foundation Trust
being investigated, LLR,
GWithin this report, it is stated
commissioned the Royal
is highly specialised. The
College of Surgeons (“RCS”)
LLR department of GOSH
to review their Paediatric
“assesses and treats some of
Orthopaedic Service and
the most rare and complex
the care provided by Mr Yaser Jabbar after
conditions affecting arms
concerns were raised about his clinical practice
and/or legs”, and there
in June 2022. Mr Jabbar joined GOSH in 2017
are often “no established
where he practised until 2022 as one of the
standard approaches” to
Consultant Orthopaedic Surgeons within the Limb
the management of these
Lengthening and Reconstruction (“LLR”) Service.
conditions either nationally
He also worked both for the NHS and privately
or internationally, with
at other London hospitals.
clinical practice often varying
between individual specialists.
The story has been widely covered in the press
and is understandably very emotive and distressing
for the families involved.
Therefore, there are a limited
number of experts nationwide.
Initially, three independent
Consultant Paediatric
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: https://media.gosh.
nhs.uk/documents/PUBLIC_TB_agenda_and_
papers_241024_3mMK1nB.pdf. 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”.
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
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 entitled,
“Patient Recall Findings within the Lower Limb
Lengthening and Reconstruction Service, part of
the Orthopaedic Surgery Department”: https://
media.gosh.nhs.uk/documents/GOSH_Patient_
Recall_Findings_within_the_Lower_Limb_
Lengthening_and_Reconstruct_KheSaiK.pdf.
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.
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