Preventing poor practice in paediatric orthopaedic surgery: lessons from recent events

Paediatric orthopaedics is an area of rapid evolution. New implants, minimally invasive techniques, and computer assisted corrective technologies offer life-changing outcomes for children with limb deformities or developmental conditions. But innovation must be carefully managed to avoid unintended harm.

NHS trusts typically consider new techniques within one of three categories:

1. New to the trust but used elsewhere
2. Completely new and not used anywhere else
3. Established procedures being applied in a new context

Each situation requires a different level of scrutiny from innovation committees, clinical governance teams, and multidisciplinary clinicians. Even where a procedure is only “new to the setting”, the trust should assess evidence, risk, monitoring requirements, and the surgeon’s expertise.

For example, established minimally invasive techniques may require formal approval when used with new patient groups. Likewise, devices such as limb lengthening systems, which have evolved from external frames to sophisticated internal mechanisms, require robust training, careful calibration, and rigorous follow up. The introduction of new implants in adult orthopaedics already goes through tightly controlled, limited rollouts with outcomes tracked; a similar discipline is needed in paediatric settings.

Surgeons joining a trust with prior experience of particular techniques bring valuable expertise, but their practice still requires local validation. Appointment committees and RCS assessors should consider both the adequacy of the surgeon’s training and the department’s readiness to support the technique safely. However, when recruitment is focused primarily on filling vacancies, these discussions can be overlooked.

The RCS review at GOSH reportedly highlighted concerns not only about an individual surgeon’s practice but also about departmental culture, communication, and hierarchy. These factors, although less visible, are often the greatest determinants of patient safety.

Paediatric orthopaedics involves a wide range of procedures - some routine, some extraordinarily complex. Variation between surgeons is inevitable, and new techniques emerge frequently. This diversity makes peer oversight essential.

In an ideal environment, multidisciplinary team (MDT) working acts as a safeguard. MDTs allow clinicians to share cases, challenge assumptions, and identify potential problems early. Yet MDT provision varies widely across trusts. Resourcing pressures can result in MDTs being minimised or deprioritised, with management preferring separate clinics to maximise throughput.

When clinicians operate largely independently, with limited structured discussion of complex cases, problems may go undetected for longer. Hierarchical departments can exacerbate this, with junior clinicians or allied health professionals feeling unable to raise concerns.

The situation at GOSH illustrates that governance structures must be supported by a culture that promotes openness and challenge, not just formal policies.

Surgical appraisal and revalidation are intended to provide ongoing oversight by assessing:

• Continuing professional development
• Surgical outcomes against national standards
• Multisource feedback from colleagues
• Reflections on professional relationships and patient engagement

However, these systems only function effectively when clinicians fully engage. Some view appraisal as bureaucratic rather than developmental. In tertiary centres, interpreting complications is particularly complex because caseloads often involve rare or severe conditions. Higher complication rates may reflect case complexity rather than poor practice, requiring sophisticated interpretation from appraisers and governance leads.

Outcome data can also be misleading without context. For example, surgeons who treat developmental dysplasia of the hip (DDH) from infancy to adulthood may show different long-term outcomes compared with colleagues who operate only on standard adult hips. Without nuanced assessment, appraisal systems can misinterpret specialised practice as underperformance.

The events now unfolding highlight the need for more meaningful appraisal structures - ones that foster continuous improvement and identify risk patterns early.

One of the most troubling aspects of poor practice cases is how long concerns may circulate before formal action occurs. Hospitals encourage staff to raise issues, yet the reality is complex. Clinicians may fear reputational damage, strained relationships, or scepticism about whether concerns will be acted upon.

Formal whistleblowing policies exist, but these require high thresholds of evidence, and the evidential burden largely falls on the person raising the concern. Clinical leads may receive leadership training, but few doctors feel prepared to challenge a colleague's technical skills or decision-making.

Parents, meanwhile, often hold early insights into issues affecting their child’s care. Yet many hesitate to complain, particularly when they trust or like their clinician, or are uncertain whether their concern is “significant enough” to report. While PALS manages formal complaints, there is limited clarity on how informal concerns are logged, escalated, or triangulated with other emerging issues.

The hospital’s decision to proactively contact families reflects the importance of transparency, but also raises questions about whether earlier concerns could have been surfaced more effectively.

Paediatric orthopaedic conditions frequently require treatment over many years; complications or late effects may emerge long after the original surgery. Determining whether concerns relate to surgical technique, disease progression, or evolving best practice can therefore be difficult.

This is why independent reviews (such as the one now underway) are essential. External experts bring an objective lens that internal teams cannot. Their insights help identify not just individual failings but systemic weaknesses in training, communication, governance, and culture.
The wider profession has an opportunity to learn from these findings, strengthening systems to prevent similar issues elsewhere.

Drawing together insights from clinicians and governance experts, several improvements stand out:

1. Stronger processes for introducing innovation: every trust should have clear thresholds for approval, monitoring, and limiting early use of new techniques.
2. More robust consultant appointment scrutiny: specialised techniques must be explicitly discussed, evaluated, and supported during hiring.
3. Consistent MDT working: MDTs should be protected and prioritised for complex paediatric conditions.
4. More meaningful appraisals: appraisal must be treated as a core professional duty, with deeper analysis of outcome data.
5. Improved speaking up culture: staff should have safe, supported pathways to escalate concerns; parents need clearer, earlier routes to share feedback.
6. National oversight for high-risk paediatric procedures: centralised data collection or extended roles for technology assessment bodies could support safer innovation.