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NHS alerts hospitals to use of incorrect fixation plate implants in series of ‘never events’

Posted: 13/02/2019


The NHS has asked hospitals to check whether the correct metal fixation plates have been used to fix fractured bones after seven patients at one NHS trust underwent surgery with the wrong implants, leading to complicated recoveries and the need for revision surgery.

NHS Improvement, the organisation responsible for overseeing improvements at NHS trust hospitals, identified that flexible plates, which are intended for reconstruction surgery, had been used to fix unstable fractures rather than rigid fixation plates. The organisation fears that the same mistakes could have been made at other hospitals because the modified flexible reconstruction plate design is now visually similar to the rigid fixation plate.

Following the report that seven patients were fitted with incorrect plates, NHS Improvement has requested hospitals across the country to check X-rays of orthopaedic surgery involving the use of a rigid fixation plate dating back to February 2018 to ensure no other cases occurred. This is thought to be approximately 5,500 cases.

Arran Macleod, a solicitor in the clinical negligence team at Penningtons Manches LLP, said: “The use of an incorrect medical device during surgery should not happen. Such instances are termed ‘never events’ and defined by NHS Improvement as ‘serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers’.

"Patients who have undergone surgery to fix an unstable fracture with a flexible fixation plate are at an increased risk of suffering problems during recovery. The fracture may take longer to heal and it could be more painful and susceptible to failure. This may ultimately lead to the patient needing further surgery. Revision surgery can be more invasive and complicated, causing the patient to endure a period of pain and suffering that wouldn’t otherwise have occurred.

“If you, a friend or family member have any concerns that a medical device used during your treatment may have been incorrect, do not hesitate to get in touch with our specialist orthopaedic team who will be able to provide you some preliminary advice on your options.” 


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