Page 7 - PIC-Magazine-Issue-26

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 identifi ed 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:
1.
Consent;
2.
History Taking, Examination,
Diagnosis and Investigation;
3.
Case Selection, Decision-Making
and Surgical Skill and Technique;
4.
Identifi cation, Management and
Ownership of Complications.
In all four areas, the report sets
out standard practice within the
UK, fi ndings of the experts and
implications for patients. Within
these four areas, examples of
standard practice were found,
along with examples of sub-
standard practice.
It was determined that of the 789 patients
investigated, 12.4% experienced some harm, and
11.9% suff ered harm attributable to Mr Jabbar.
In area one, it was found
that there was “satisfactory
documentation of risks and
benefi ts in many cases”, but
there were “missing, incomplete
or illegible consent forms,
overuse of generic language, and
insuffi cient documentation of
alternative treatment options”.
Further, “there were instances
where the procedure undertaken
diff ered 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
identifi ed 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 fi ndings
over clinical symptoms. Some
serious problems were found
including poor planning, putting
Dr Louisa Sherlock
No5 Barristers' Chambers
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 insuffi cient safety
netting advice.
In area four, whilst there were
examples of prompt recognition
and eff ective management
of complications, cases were
identifi ed 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 aff ect 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 aff ected.
PARTNERS IN COSTS
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