How claims can come about
Claims against GPs following an alleged delayed diagnosis of developmental dysplasia of the hips can arise many years after the allegedly negligent act, because a child can bring a claim at any point up until their 21st birthday. In addition, the impact of any delayed diagnosis can take many years to become apparent, as the child grows and reaches skeletal maturity.
Although the vast majority of claims against NHS GPs arising out of incidents after 1 April 2019 are dealt with under the Clinical Negligence Scheme for GPs, the MDU is still being notified of claims against GPs following developmental dysplasia of the hips when the consultation in question occurred prior to April 2019, because of the lag between the events in question, the diagnosis and a claim actually being brought.
A typical claim that the MDU might see arises following the six-eight week check. It may be alleged either that the check was not performed to a reasonable standard, or that there was a subtle abnormality that was not acted upon, such as the hips feeling stiff or clicky.
Considering a case
To investigate a case against a GP in these circumstances, the MDU will first obtain copies of the patient's medical records, including the Red Book. We would also get some information from the GP about how they conduct the six-eight week check, including details of the examination carried out, which formal tests are performed and how.
Given these claims can be brought many years after the appointment in question, detailed records of which tests were carried out are very helpful - but the GP will often still have to rely on what their usual practice would have been at the time since they are extremely unlikely to remember the appointment itself.
The MDU will then obtain expert advice from an independent GP expert, and an independent paediatric orthopaedic expert.
The paediatric orthopaedic expert will be asked to give an opinion on what the likely findings were on the date of the examination, but also on the prognosis for the child's hip(s) given when the condition was diagnosed, compared to how the hips would have functioned with earlier diagnosis.
Once the experts' advice has been obtained, the MDU will be able to advise the member how the claim should be responded to.
Given these claims can be brought many years after the appointment in question, detailed records of which tests were carried out are very helpful.
Case report:
The scene
A child was born in hospital at term by spontaneous vaginal delivery, and the initial hip check after birth was noted as satisfactory.
The patient then attended her GP - an MDU member - for the six-eight week check, at the age of nine weeks. The GP circled the hips as "satisfactory" in the Red Book, and recorded in the computerised records that the hip examination had been normal.
However, by the age of 18 months, the child still was not walking and her mother brought her for review with a GP, raising concerns that the child didn't seem to be willing to bear weight. The mother also said that when the six-eight week check had been done, the GP carrying out the check had commented that the hips had felt "a bit clicky". The GP referred the patient to the paediatric orthopaedic surgeons.
When the patient was seen by the paediatric orthopaedic surgeon, imaging confirmed dislocation of the right hip. An attempt was made at closed reduction, but this was unsuccessful and the patient underwent an open reduction, with a revision procedure approximately six months later.
The claim
A claim was brought against the MDU GP member who carried out the check at nine weeks of age, alleging there was a failure to act on the finding that the hips had been "a bit clicky". The claim alleged that referral to a paediatric orthopaedic surgeon was mandated in light of this finding, which would have resulted in diagnosis of developmental dysplasia of the right hip. This in turn would have been successfully treated in a hip spica cast, resulting in a good outcome with no long term sequelae.
It was alleged that because of the delay, the patient required surgery and would go on to develop early osteoarthritis, and would need at least one hip replacement and a revision during her lifetime.
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How we helped
The MDU instructed a solicitor to act on behalf of the GP member, and the two met to draft a statement of the GP's usual practice when carrying out a six-eight week check. The member couldn't remember the appointment, which by this point had been several years earlier, but her statement detailed the hip examination she would have performed and how she carried out the Barlow and Ortolani tests.
This statement was given to an independent GP expert, along with the medical records, who was supportive of the GP's care on the basis that there were no risk factors for developmental dysplasia of the hip, and an appropriate examination had been carried out with no abnormalities identified. Even if the hips had been "a bit clicky", assuming no other abnormalities, onwards referral was not required.
The MDU also obtained expert paediatric orthopaedic advice. This expert held that the developmental dysplasia was probably present at the time of the six-eight week check, but would not necessarily be detectable on examination at this age.
However, if the patient had been referred at this time, a paediatric orthopaedic surgeon may have identified some hip instability, and an ultrasound would have confirmed the diagnosis. The patient would have been treated with a hip spica cast, which would have resulted in normal hip development with no need for hip replacement in the patient's lifetime. The expert agreed that because the diagnosis wasn't made until the patient was 19 months old, she would be likely to develop premature osteoarthritis.
After getting the expert advice, the MDU served a response to the claim on behalf of the GP, and the claim was subsequently discontinued. However, this was not confirmed until nearly two years after the claim was first notified to the MDU, and more than eight years after the appointment in question.
Dr Claire Wratten
Dr Claire Wratten is a senior medical claims handler and claims team manager, who joined the MDU in 2006 from a background in nephrology and general medicine.
See more by Dr Claire Wratten