Orthopaedic review

Reviews such as this are an important part of our work to ensure the safety and quality of our services.

We asked the Royal College of Surgeons to review our Paediatric Orthopaedic Service and the care provided by Mr Jabbar after concerns was raised about his practice.

In addition to asking the College to review our service, we also contacted the General Medical Council, which regulates doctors, and the Care Quality Commission, which regulates healthcare, to inform them of initial concerns that were raised about the surgeon.

The surgeon in question has not worked at Great Ormond Street Hospital since October 2022.

When the decision was made to review Mr Jabbar’s patients, we determined that it was essential to include all patients who had clinical contact with him, rather than approximately 200 patients suggested by the RCS in their report. This approach was to ensure a thorough assessment of whether any harm could have occurred at any stage of a patient’s care journey.

A group of independent Paediatric Orthopaedic Consultants from other UK hospitals reviewed specific aspects of a patient’s care, including consent, decision-making and assessment.

They used available medical records and imaging to assess whether a patient had come to harm, using NHS England guidelines to grade any harm as mild, moderate or severe. For each patient, the reviewers provided recommendations about whether any further care was required.

The review outcomes were sent to all patients and their families. We also offered to meet with any patient and family who would like to, regardless of whether harm had been found.

Neither the Royal College of Surgeons nor the GOSH report contain any individual patient information.

In response to the RCS review into the Service, we undertook significant work to make the care we give better and safer for all patients. The RCS review set out 122 recommendations for the hospital, all of which have been completed. These recommendations were predominantly focused on improving the work of the Orthopaedic Service, however there were broader actions that we have applied across the hospital.

Within the Orthopaedic Service, actions include:

• Standardising the way we accept patients and manage waiting lists
• Ensuring every surgical patient is reviewed by a large team before and following surgery (MDT)
• Fortnightly meetings with Royal National Orthopaedic Hospital to discuss complex cases with a wider specialist team
• Strengthening the processes we have to discuss care that has not gone to plan at monthly Mortality and Morbidity Meetings
• Agreeing outcome measures for children and young people with limb differences, conditions that affect the foot and ankle and for neuromuscular conditions which require orthopaedic surgery

Wider learnings and actions that are being applied across the hospital include:

• Standardising multidisciplinary teams (MDT) and mortality and morbidity (M&M) meeting governance
• Reviewing outcome measures for our services
• Investing in our clinical leaders through speciality lead training
• Further developing our Speak Up culture including supporting patients to raise concerns
• Improving our induction processes including training a cohort of mentors

Thousands of patients are treated at GOSH every year and the overwhelming majority have a positive experience at our hospital.

We asked all of our patients to complete the Friends and Family Test and in November 2025 our inpatient experience score – the satisfaction rating of their overall experience - was 99%.

The Care Quality Commission (CQC)– our regulator - NHS England and the College received regular updates throughout the patient review process and were satisfied with the steps we are taking to improve the Orthopaedic Service. In early 2025, we received a Good rating from the CQC for patient safety.

The patient recall process  concluded and we have completed all recommendations made to us by the RCS. The extensive learnings from this process have been taken forward as part of a hospital-wide Quality and Safety Improvement Programme to significantly strengthen our governance across our clinical services and to minimise the risk of something like this happening again.

As the commissioner of services, NHS England has a responsibility to make sure the NHS learns and improves when standards fall short. NHS England (London region) has confirmed it is commissioning an independent patient safety investigation to examine how we responded when potential harm was identified within the limb-lengthening service.

This will add to the existing understanding of what happened in this case and make sure that the NHS learns from this to protect children, young people and their families in the future.

Independent Patient Safety Investigations are standard practice in the NHS where harm has occurred to make sure learning is captured and shared.

The investigation will focus on governance and organisational culture at GOSH. It aims to:

• promote openness and transparency about what occurred and the factors involved
• identify opportunities for improvement to reduce the likelihood of similar events in the future
• provide recommendations to strengthen the delivery of health services.

This review will complement the RCS assessments by concentrating on systems and processes, rather than individual cases or clinical harm.

A company and an independent chair are in the process of being appointed with the investigation expected to commence in February. We will keep families updated on this as it progresses.

We are working closely with our Local Authority Designated Officer to keep them informed throughout the patient care reviews, as is standard practice under the Working Together to Safeguard Children guidance.

Local Authority Designated Officers work with organisations including children's social care, the police, and employers to manage allegations against adults who work with children.

We appreciate families may wish to discuss their own concerns directly with the police and can do so through normal routes including calling 101 or visiting their nearest station. For more information visit www.police.uk/pu/contact-us/.

You can also find helpful advice and support from AvMA, a charity for patient safety and justice.