Decision making after hip dislocations
19. Ms I complains Dudley and ROH should have either done or referred her mother for a full hip replacement instead of repairing the hip every time it was dislocated.
20. During 2022, Dudley admitted Miss N on the following times due to dislocation of her left hip:
• 25 to 28 March • 15 to 20 April • 30 April to 6 May • 13 to 19 May • 29 May to 1 June • 1 to 23 June • 4 July to 6 August • 29 August to 21 September.
21. Dudley made a referral to ROH on 31 May 2022 for a consultation. It explained in its complaint response that unfortunately, waiting times for consultations at ROH are long and this is something Dudley cannot control because ROH is a separate trust.
22. It said it appreciated how frustrating it must be for Miss N and the family when she had dislocated her left hip several times while waiting for an appointment and review. Sadly, the surgery Miss N needed (revision hip surgery) for her dislocating hip was not something Dudley is equipped to deal with. This was the reason for referral to ROH.
23. In ROH’s complaint response it says a total hip replacement had already been done before which then started dislocating.
24. ROH explained there are considerable risks in doing a full revision (after dislocations) including higher risk of bone loss, fracture of the bone around the impact, blood transfusions and infections. ROH said sometimes it needs to do ‘limited revision’ that involves only some of the components being replaced to try to achieve the same goals.
25. ROH said there are several options when a hip replacement becomes unstable (starts dislocating). It has to make a judgement about how much capture the head of the hip has in the new cup. There are a lot of downsides to doing this and there are still no guarantees with the surgery.
26. During the consenting process it is common to consider either a total or partial (limited) revision. The situation can change at any time during surgery. It said it will often recommend doing the smaller procedure (and taking the lowest risk) and if possible, leave future options available.
27. Our orthopaedic adviser said there are no standards or guidelines for management of hip dislocations after hip replacement. But, the principles (in line with good clinical practice and studies) are to reduce the dislocation (for example by manipulation which is called closed treatment) at first and then monitor the patient. Closed treatment describes a method of treating a fracture of dislocation without surgically opening the treatment site. In cases of ongoing dislocations, most patients need revision surgery.
28. Cochrane Library guidance says:
‘About 3 out of 100 people who have this surgery [hip replacement surgery] will dislocate their hip. Dislocating a hip causes much pain and other problems. There are many ways to fix a dislocated hip. Usually, the first time a dislocation occurs the hip is put into a cast or brace. But repeated dislocations usually need to be fixed with surgery. Unfortunately, the causes for dislocation are many and some are not known making it difficult to know the best way to fix it.’
29. The medical evidence shows Dudley reduced (physically moving the joint back into place) Miss N’s hip dislocations many times.
30. The records show Dudley at first admitted her after a hip dislocation in March 2022. Her first total left hip replacement surgery was done in 2010. Our orthopaedic adviser said the initial treatment of this would be an MUA to reduce the dislocation and check stability. This was appropriately done at Dudley in line with good clinical practice.
31. In May 2022, Dudley referred Miss N to ROH in line with GMC Good medical practice. This says:
‘b. promptly provide or arrange suitable advice, investigations or treatment where necessary
c. refer a patient to another practitioner when this serves the patient’s needs.’
32. Dudley made the referral in May 2022 when it realised the hip replacement was unstable, had dislocated many times and would need revision surgery. Our orthopaedic adviser said the referral was timely as it would have been best to try closed treatment before referring for surgery. The outcome would not have been different with an earlier referral as Miss N would still have needed surgery at ROH and any delay in treatment would depend on when ROH could see her and arrange surgery.
33. Even if revision surgery was done earlier, it is likely Miss N will still have needed further revisions due to persistent instability (as happened in this case).
34. In the meantime, Dudley made sure treatment was given to Miss N by reducing the dislocations as and when they happened, in line with good clinical practice and clinical studies.
35. During Miss N’s treatment at ROH, it advised revision surgery for management of ongoing dislocations in line with the Bone and Joint Journal guidance, that says:
‘Treatment of recurrent hip dislocation begins with an assessment of the cause.
Surgical options include exchange of modular components [ball of the hip joint] to increase soft-tissue tension, or a switch to a larger head diameter, including bipolar or tripolar arthroplasty [replacement surgery for joints], and use of an acetabular lip [part of the hip socket]. Malposition and impingement [where the ball and socket of the hip joint rub abdominally] must be corrected. Soft-tissue or trochanteric [part of the leg bone where muscles are attached] advancement, and the use of constrained liners [fits inside the socket to improve stability] should be a last resort.’
36. The medical records show ROH carried out surgery in August, September and November 2022. The August surgery was limited revision left hip total hip replacement. The surgery in September involved changing the liner to a more constrained liner which cannot dislocate easily and a full revision of acetabular (socket of the hip joint) component was done in November.
37. We considered whether the revision procedures between August and November were the appropriate treatments in line with good clinical practice, studies and guidance.
38. Our orthopaedic adviser said it is reasonable to try the least invasive options first to attempt to stabilise the hip replacement if possible. This decision can only be taken by the operating surgeon at the time of revision. There is a higher risk of failure with limited revision but there are also lower risks of complication related to more complex surgery and the risk/benefits need to be assessed by the surgeon during the operation.
39. The first treatment should be a reduction of the dislocation, which Dudley did. In the case of ongoing dislocations, as in Miss N’s case, referral for revision surgery was made in line with operative and non-operative treatment options for dislocation, dislocation after total hip replacement and GMC guidance.
40. We understand Ms I questions whether Dudley and/or ROH should have either carried out or referred her mother for a full hip replacement instead of repairing the hip every time it was dislocated. We are sorry to learn about the distress this caused her and her mother. The medical evidence shows the hip treatments and referrals were in line with the relevant guidance. We cannot see a sign of a failing.
Dislocation during transfer
41. Ms I complains that due to a lack of monitoring by either Dudley or ROH, her mother dislocated her hip before her full hip replacement, when she was transferred between Dudley and ROH in September 2022.
42. Dudley did not comment on this in its complaint response.
43. ROH said in its complaint response that after the consultant orthopaedic surgeon at ROH called Ms I on 16 September, it explained that unfortunately Miss N had another dislocation during the transfer.
44. Within ROH’s clinic letter to Miss N dated 28 September 2022, ROH’s consultant orthopaedic surgeon said they were sorry to learn she had a further dislocation since her last appointment on 16 September. The surgeon said Miss N denied any clear history of falls or any incident that caused her hip to dislocate again.
45. The medical evidence shows Miss N dislocated her hip at some stage during transfer from ROH to Dudley.
46. Our orthopaedic adviser has carefully reviewed the medical records. They said the records show there was no lack of monitoring by either Dudley or ROH which resulted in Miss N dislocating her hip. Unfortunately, further dislocation is a risk of revision surgery. ROH told Miss N about this risk before the revision surgeries in August and September as per the clinic letter from ROH and the consent forms. The dislocation itself is not evidence that something went wrong.
47. We are sorry to learn Miss N had another dislocation during the transfer between ROH and Dudley and about the impact this caused. There is no evidence that there was a lack of monitoring by either ROH or Dudley which resulted in this dislocation. We cannot see evidence of a failing.
Care plans
48. Ms I complains Dudley discharged her mother with poor care plans every time it admitted her for a dislocated hip.
49. In Dudley’s complaint response it explained that as Miss N lived in Worcester, it does not have a say in the amount of care she has after her discharge from hospital. It said the hospital process is that it completes the necessary paperwork before discharge and sends it to Worcester Social Services (WSS is not part of this complaint). It will then be told when staff at WSS have capacity and they will then complete an assessment in the community.
50. It said packages of care (POC) were available after Miss N’s discharges on 21 April, 6 May, 19 May, 5 June and 23 June 2022.
51. In its complaint response Dudley said after speaking with Ms I and listening to her concerns about Miss N returning home, it agreed Miss N would go into a temporary bed and the occupational therapist (OT) arranged this. It said it completed two mental capacity assessments for Miss N and both indicated she had full capacity to make her own decisions about her discharge from hospital.
52. We considered whether Dudley should have put in place care plans for Miss N when it discharged her.
The relevant guidelines are the NICE guideline NG 27. Under section ‘Discharge Planning’ is says:
‘Section [1.5.14] The discharge coordinator should work with the hospital and community‑based multidisciplinary teams and the person receiving care to develop and agree a discharge plan.
Section [1.5.15] The discharge coordinator should ensure that the discharge plan takes account of the person's social and emotional wellbeing, as well as the practicalities of daily living.’
53. The medical records show Dudley discharged Miss N six times between April and June 2022, after a dislocated hip. Because Miss N lived outside Dudley’s area, it sent a POC to WSS before her discharge.
54. Between July and September, Dudley admitted Miss N two more times after she had hip dislocations. During this time Dudley transferred Miss N to ROH for assessment and surgery.
55. Our OT adviser said a POC is not needed when a patient is transferred to another trust (ROH in this case). This would become the responsibility of the trust the patient was referred to. In this case it would be ROH’s responsibility.
56. Dudley should put in care plans for Miss N for discharge when leaving hospital, as set out in the NICE guidelines.
57. Based on the medical records, our OT adviser said that between March and June 2022 Dudley put in place care plans for Miss N which were appropriate for continuing care in the community, in line with NICE guidelines.
58. For example, during the April admissions Dudley identified follow-up care was needed on discharge. It referred Miss N to WSS for a POC to be put in place and this was accepted. Dudley spoke with WSS as part of its triage process and fed back all information that was needed to support an assessment of Miss N going for a POC. This was in line with NICE guidance that says:
‘The discharge coordinator should arrange follow‑up care. They should identify practitioners (from primary health, community health, social care, housing, and the voluntary sector) and family members who will provide support when the person is discharged and record their details in the discharge plan.’
59. When Miss N was back in the community it would be up to WSS to decide what is needed. As the evidence shows Dudley made the referral and spoke with WSS to make sure ongoing care was provided after discharge from hospital, it complied with the NICE guidance.
60. Between 29 May and 5 June, the medical notes record Miss N’s family were not happy with her only having one morning call from carers and requested more. WSS was aware at the time and Dudley completed the assessment on identifying increased care need on discharge. This shows the handing over of continuing care to the relevant services as stated in the NICE guidelines.
61. Dudley also looked at other discharge options for Miss N between March and September 2022, as stated in the therapy notes. It spoke with the Worcester Local Authority (WLA), including WSS to look at intermediate care as options because she was becoming unfit for discharge and needed to wait for a hip replacement at ROH.
62. Dudley worked with social services to try and find an intermediate care bed for Miss N for continuing care in the community on discharge. This is in line with NICE guidance.
63. Our OT adviser said that between March and September, Dudley put care plans in place according to the needs of Miss N at the time. As her needs changed, Dudley stayed within NICE guidelines to make sure the correct care plan was made at the time of her discharge.
64. We are sorry to learn of Ms I’s complaint and the impact these events had on her and her mother. We have carefully considered all the relevant evidence, including her and Dudley’s account, medical records and clinical advice. We have decided that Dudley put in place care plans every time her mother was admitted for a dislocated hip, in line with NICE guidelines. There is no sign of a failing.
Lost clothes
65. Ms I complains Dudley lost her mother’s clothes during one of her admissions for her hip.
66. We have considered the records and contacted both Dudley and ROH and there is no evidence that Ms I complained about this issue to them. This does not mean Ms I did not raise this matter either with the complaints team or the hospital, but there is not enough evidence in the medical records and complaint file to show she did.
67. We have considered whether we could reasonably investigate this complaint.
Unfortunately, there is not enough evidence available for us to practically investigate this concern and make a decision. We are sorry to learn about her and her mother’s experiences. Taking all the above into account, we cannot consider this part of her complaint.
68. Our decision is not made without recognition of the impact this has had on Ms I and Miss N. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.