NHS Improvement have issued a safety alert and ordered a review of over 5500 patients treated at 140 hospital trusts since February 2018 amid concerns that the wrong type of plate may have been used for fracture patients. The British Orthopaedic Association has estimated that 30 to 40 patients are likely to be affected at each NHS trust.

The alert came after seven never events involving use of the wrong fracture fixation were reported by one NHS Hospital trust. A review at prompted when two patients required surgery after the metal plates fixing their fractures buckled had found that flexible plates designed for use in reconstructions had incorrectly been used instead of rigid plates to support fractured bones. 

The difficulty arose following a change in the design of reconstruction plates which means they now look similar to dynamic compression plates. The two types of plates have different strengths of rigidity and are not interchangeable. According to the British Orthopaedic Association use of the wrong plate puts patients at risk until their fractures have fully healed and they may require corrective treatment. NHS Improvement has suggested changes to theatre procedure to prevent recurrences, including that hospitals should purchase reconstruction plates in individual sterilised packs and store them separately for use only when specifically required.

Whilst the NHS Trust in question here has not been identified by NHS Improvement, never event statistics for the period from April to December 2018 show that there were 54 never events reported involving the use of an incorrect prosthesis/implant. The majority of the prosthetic/implant never events involved orthopaedic prosthetics, including 21 hip replacements, 9 knee replacements and 4 incidents where the wrong fracture fixation plate. The data also shows that 12 of the 54 prosthesis/implant-related never events occurred at Walsall Healthcare NHS Trust, which is 6 times the number reported at any other Trust. (https://improvement.nhs.uk/documents/3700/Provisional_Never_Events_data_1_April_to_31_December_2018_FINAL.pdf)  

Aidan Fowler, national director for patient safety at NHS Improvement said: “We are asking all hospitals in England who provide orthopaedic surgery to review X-rays for their patients who have had surgery involving plates in the past year."

Hospitals have been given 3 months to identify all patients who affected and to review their X-rays and report any incidents. It is understood that patients treated before February 2018 will likely have fully healed or have experienced problems before now. 

If you are affected by the NHS Improvement review or have concerns regarding orthopaedic or other treatment you or a loved one has received, then you are welcome to contact one of our specialist solicitors for advice on 01865 781000 or clinicalneligence@freeths.co.uk

The Freeths national clinical negligence team is headed by:

Carolyn Lowe, Partner (Oxford/Milton Keynes) on 0186 578 1019 or carolyn.lowe@freeths.co.uk 

Karen Reynolds, Partner (Derby/Stoke) on 0845 272 5677 or karen.reynolds@freeths.co.uk 

Jane Williams, Partner (Leicester) on 0845 272 5724 or jane.williams@freeths.co.uk