The number of clinical negligence claims in the UK is constantly increasing. As a specialty, trauma and orthopaedic surgery has one of the highest numbers of negligence claims. 1. This study analyses NHS Litigation Authority (NHSLA) claims in trauma and orthopaedics between 2004 and 2014. . A formal request was made to the NHSLA under the Freedom of Information Act in order to obtain all data related to claims against orthopaedic surgery. It was found that the number of claims, and percentage of successful claims, has been constantly increasing over this period, with compensation paid of over £349 million.* Errors in clinical management accounted for the highest number of closed claims (2933 claims), costing over £119 million.*. The level of compensation paid out has a significant financial impact on the NHS. Reforms need to be made in order to tackle the high cost of legal fees generated by these claims, which further drain the limited resources available to the NHS

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.

We present a review of claims made to the NHS Litigation Authority (NHSLA) by patients with conditions affecting the shoulder and elbow, and identify areas of dissatisfaction and potential improvement. Between 1995 and 2012, the NHSLA recorded 811 claims related to the shoulder and elbow, 581 of which were settled. This comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total of £18.2 million was paid out in settled claims. Overall diagnosis, mismanagement and intra-operative nerve injury were the most common reasons for litigation. The highest cost paid out resulted from claims dealing with incorrect, missed or delayed diagnosis, with just under £6 million paid out overall. Fractures and dislocations around the shoulder and elbow were common injuries in this category. All 11 claims following wrong-site surgery that were settled led to successful payouts. This study highlights the diagnoses and procedures that need to be treated with particular vigilance. Having an awareness of the areas that lead to litigation in shoulder and elbow surgery will help to reduce inadvertent risks to patients and prevent dissatisfaction and possible litigation. . Cite this article: Bone Joint J 2014; 96-B:574–9

Metal-on-metal (MoM) hip resurfacing was developed in the 1990s by surgeons in Birmingham, UK, as a surgical solution to the problem of osteoarthritis in younger, more active patients. Early results were promising and the procedure gained in popularity. However, adverse reports of soft-tissue reaction and failure started to appear from 2008 onwards. Surgeons may be asked to write medico-legal reports on the surgical aspects of an individual case for claimant lawyers or in defence for the NHSLA or indemnity insurers. The purpose of this article is to cover some of the aspects of the operation that may be considered in such medico-legal reports

Aim. The aim of this study is to evaluate the causes of litigation in spinal surgery and to identify preventable causes. Methods. Retrospective analysis of all claim data made available under Freedom of information act from NHS Litigation Authority between years 2000 to 2010. Results. A total of 581 (331 Orthopaedics and 250 Neurosurgery) claims were filed in England and Wales, of these 543 cases were settled while 38 cases were pending. 371 (69%) of 543 settled resulted in payout but 172 (31%) claims were successfully defended by the NHSLA. Average payout was £63,573 total £ 36935933 maximum payout of £ 1800000). This figure rose to average of £ 95125, (Total £553627720) when defence and claimant costs were included. The allegations categories were 123 failure or delay in diagnosis, 108 intra operative problems, 90 failure or delay in treatment, 45 suboptimal consent and in 40 failure to recognise complications. The successful litigations were result of neurological injury in 143, un necessary operation in 37, avoidable pain in 29, death 15 and Misc 31. Conclusion. Litigation can in part be attributed to the “no win no fee” culture; steps that can be taken to reduce the number of successful claims. Failure or delay in diagnosis and Intra operative problems can partially be attributed to lack of resources and or expertise emphasising the need for spinal surgery to be concentrated in specialist centres. Documented informed consent can also potentially decrease litigation. No conflicts of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

The results of hip and knee replacement surgery are generally regarded as positive for patients. Nonetheless, they are both major operations and have recognised complications. We present a review of relevant claims made to the National Health Service Litigation Authority. Between 1995 and 2010 there were 1004 claims to a value of £41.5 million following hip replacement surgery and 523 claims to a value of £21 million for knee replacement. The most common complaint after hip surgery was related to residual neurological deficit, whereas after knee replacement it was related to infection. Vascular complications resulted in the highest costs per case in each group.

Although there has been a large increase in the number of operations performed, there has not been a corresponding relative increase in litigation. The reasons for litigation have remained largely unchanged over time after hip replacement. In the case of knee replacement, although there has been a reduction in claims for infection, there has been an increase in claims for technical errors. There has also been a rise in claims for non-specified dissatisfaction. This information is of value to surgeons and can be used to minimise the potential mismatch between patient expectation, informed consent and outcome.

Cite this article: Bone Joint J 2013;95-B:122–6.

The aim of this study was to review the data held with the NHSLA database over the last 10 years for negligence in spine surgery with particular focus on why patients ‘claim’ and what is the likely outcome. Anonymous retrospective review. We contacted the NHSLA and asked them to provide all data held on their database under the search terms ‘spine surgery or spine surgeon.’. An excel sheet was provided, and this was then studied for reason of ‘claim’, whether the claim was open/closed and outcome. A total of 67 claims of negligence were made against spinal surgeries during this time (2000-09). The number of claims had increased over the last few years: 2000-03, n= 8, 2004-06, n= 46. The lumbar spine remains the most common area (Lumbar: 55/67, Thoracic : 6/67, Cervical 6/67). Documented reasons for claims were post-operative complications (n= 28; 42%), delayed/failure to diagnose (n=24; 36%), discontent with preoperative assessment including consent (n=2; 3%), intra-operative complications (n= 10; 15%) and anaesthesia complication (n=3; 4%). Twenty were closed and 47 remained open. The number of successful claims was 8/20 (40%). The mean compensation paid out was £33,409 (range was £820.5 to £60,693). The number of claims brought against spinal surgeries is on the increase, with the most common area being the lumbar spine which perhaps is not surprising as this is the most common area of spinal surgery. Common reasons are post-operative complications and delay/failure to diagnose. The ‘success’ of these claims over the last 10 years was 8/20 (40%) with mean compensation paid out was £33,409. Ethics approval: None;. Interest Statement: The lead author is the CEO and founder of a Personal Injury/Medico-Legal company

To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation. Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008). Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group. Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms. NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows. Orthopaedic. 60. Accident and Emergency. 32. Other. 25. The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel. MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder. Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory

We review all litigation brought against English Orthopaedic departments involving children under the age of 16 and attempt to highlight areas where they might be avoided. The NHSLA (the National Health Service Litigation Authority) is a special Health Authority responsible for handling negligence claims made against NHS bodies in England. In addition to dealing with claims when they arise, there is an active risk management programme to help raise standards of care in the NHS and hence reduce the number of incidents leading to claims. By analysing the claims data, we have had the opportunity to see trends for which Trusts have litigation brought against them, how much this costs the Health Service and most importantly how this information can aid in clinical practice. Between 1995 until 2005/06 there were 408 cases involving orthopaedics in England that had reached a conclusion. Of those considered in our study (341), by far the most common broad category for litigation is missed or delayed diagnosis of a condition 179 cases (57% of all litigation cases) with 44% (80 cases) of those being upper limb traumatic injuries. Humeral supracondylar fractures and elbow injuries constitute 24% (44 cases) of all missed diagnoses with each having an average total payout of £27,998. Missed or poorly managed developmental disorders of the hip (DDH or SUFE) also have large total payouts. Other common causes for litigation are intra-operative errors with poor results/complications for fixation of humeral supracondylar fractures again being the most common. Complications of plasters also represent 7.3% of all claims, all with high total payouts. In assessing these trends, we suggest highlighting the potential for error during training of juniors and taking extra care during clinical practice. There are also implications identified for the planned provision of Orthopaedic care of children

Background: Procedures performed at the incorrect anatomical site are perceived as rare events. However, they can be devastating for patients and doctors. In 2007, the Chief Medical Officer for England highlighted surgical site errors as an area of concern. Evidence from the UK and North America suggests that these events are more common than we think. We present our findings on the rates of surgical errors in England and Wales. Methods: We obtained information from the National Patient Safety Agency (NPSA) and the NHS Litigation Authority (NHSLA) detailing reported cases of surgical error in England and Wales in the time period 1995–2007. This information was evaluated in conjunction with data detailing the total number of operations performed in England and Wales for the same time periods. Results: Since 1995 there have been 292 cases of errors recorded on the NHSLA database. Orthopaedic surgery was the worst offending speciality with 87 cases (29.8%). There were 49 cases (16.8%) in dental surgery and 40 cases (13.7%) in general surgery. The most commonly affected sub-specialty area of orthopaedic surgery was the hand (21 cases), followed by foot and ankle (18 cases) and spine (16 cases). The total cost of the cases which have been settled was £2,252,752.58. For the year 2006–2007 the risk of an event in orthopaedic surgery was calculated to be 1 in 105,712 cases. The risk in general surgery and obstetrics and gynaecology during this period was 1 in 353,511 and 1 in 133,371 respectively. Discussion: Orthopaedic procedures featured more commonly on the NHSLA database than any other specialty. Rates were also higher after adjustment for case load. We would like to draw attention to policies such as the WHO surgical safety checklist which aim to reduce the occurrence of such adverse incidents

Procedures performed at the incorrect anatomical site are commonly perceived as being relatively rare. However, they can be a devastating event for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong-site, wrong-procedure and wrong-patient events occur more commonly than we think. Furthermore, their incidence may be increasing as NHS Trusts increase the volume and complexity of procedures undertaken in order to cope with increasing demands on the system. In previous studies from North America orthopaedic surgery has been found to be the worst-offending specialty.

In this paper we review the existing literature on wrong-site surgery and analyse data from the National Patient Safety Agency and NHS Litigation Authority on 292 cases of wrong-site surgery in England and Wales. Orthopaedic surgery accounted for 87 (29.8%) of these cases. In the year 2006 to 2007, the rate of wrong-site surgery in England and Wales was highest in orthopaedic surgery, in which the estimated rate was 1:105 712 cases.

Introduction: There are risks attached to performing hand surgery and not just due to the fact that there are many important structures in a compact area, but because of increasing litigation. To date the cost of litigation is unknown. We have reviewed NHSLA data for closed litigation claims from 1995–2001. Method: NHSLA provided data detailing litigation claims and settlements for orthopaedic hand problems. Data sets include: incident date, creation date, incident details, damages paid, defence costs, claimant costs, total claim, cause, injury location, speciality. We analysed the data with respect to: A& E, inpatients, out-patients department and surgery to understand where most claims were made and subsequent costs. Results: There is a clear trend of increasing numbers of litigation cases, successful claims and settlement amounts. The clinical areas making the most claims and resulting in the greatest costs are: 1-Surgery, 2-Outpa-tients, 3-A& E, 4-Inpatients and lastly 5-Administration. The top 5 pathologies claimed for are: 1-wrist fracture, 2-carpal tunnel release, 3-ganglion excision, 4-metacarpal fracture, and 5-missed scaphoid fractures. Conclusion: This data is very interesting as litigation is a very emotive and sensitive issue. We confirm that litigation is on the rise and needs to be addressed. It’s evident that the majority of claims involve routine procedures or routine management decisions. Of note there are no cases relating to more complex hand surgery or difficult management issues