Frequently Asked Questions: Independent Audit on Hip Surgery Thresholds for Children with Developmental Dysplasia of the Hip(DDH)

Why did this audit happen?

A staff member made a protected disclosure, which raised concerns that CHI at Crumlin, CHI at Temple Street and National Orthopaedic Hospital Cappagh (NOHC) may have used differing criteria to determine whether DDH surgery was required.

In July 2024, CHI and NOHC confirmed they would undertake a joint clinical audit to examine a random and anonymised sample of DDH surgeries performed between 2021 and 2023. The clinical audit was conducted by a UK paediatric orthopaedic consultant with specialist expertise in this area and is now complete.

What did the audit find?

The audit reviewed 147 random and anonymous cases across the three hospitals. Based on criteria that had been retrospectively applied for the purpose of the audit, it found:

Thresholds for recommending pelvic osteotomy procedures varied between CHI at Crumlin, CHI at Temple Street and The National Orthopaedic Hospital in Cappagh. Based on the criteria that had been retrospectively applied for the purpose of the audit, the auditor raised concerns about the indications for surgery in many cases in CHI at Temple Street and NOHC. 

This group of patients will be contacted directly to explain what this means and advise on the next steps for them.

Children who had surgery at CHI at Crumlin were found to have been appropriately selected for surgery based on the current international standards used by the auditor.

Regrettably, the audit identified one case from the review sample where a child experienced complications due to the surgical approach recommended to them. This family has been contacted and supported through an open disclosure process.

What criteria did auditor use for the audit?

The auditor used literature that was based on data on radiological indices that predict for persisting dysplasia in this setting, based in the main on acetabular index (AI).

This is complex and clinical language but we are aware that parents would like to know this information.

What does “thresholds for surgery” mean?

A “threshold” refers to the clinical criteria or a set of standards and medical tests used to decide whether surgery is needed. This includes X-ray findings, the child’s symptoms, family history, age and overall hip development.

Why would thresholds be different at different hospitals?

Differences in decision-making may arise from a surgeon's clinical judgement, local practices, surgical education and experience.

Surgeons in CHI at Temple Street and NOHC were using a less-invasive DDH surgical technique, when compared to traditional methods, and were using different thresholds for DDH surgery based on this.

It is important now that we align surgical decision-making across all sites.

What is skeletal maturity?

Skeletal Maturity is a measure of bone development. It is an approximation, but girls tend to reach skeletal maturity at 12 years old, and boys at 14 years old.

For the purpose of this follow-up review to skeletal maturity, these age groups will be used as the framework.

Did the audit find that any of the audited surgeries were wrong or harmful?

Regrettably, the audit identified one case from the review sample where a child experienced complications due to the surgical approach recommended to them. This family has been contacted and supported through an open disclosure process.

My child had DDH surgery in CHI at Crumlin, was their surgery necessary?

Children who had surgery in CHI at Crumlin were found to have been appropriately selected for surgery based on the current standards used by the auditor.

Children's Health Ireland has written to these families to confirm this information. These children will continue in their normal follow up processes, including follow up to skeletal maturity.

Children who had their surgeries in Crumlin are not part of the CHI MDT clinical reviews.

My child had DDH surgery in CHI at Temple Street or National Orthopaedic Hospital Cappagh, was their surgery necessary? 

Following the publication of the audit the HSE has commissioned an External Expert Panel (EEP) following the publication of Mr. Simon Thomas’ Independent Medical Audit (DDH Audit). The review will assess the appropriateness of pelvic osteotomy procedures carried out in CHI (Temple Street) and NOHC between January 2010 and March 2025.

The HSE is forming an External Expert Panel (EEP) made up of international clinical experts. These experts will carefully review the original decision to perform your child’s surgery. Preparatory work is underway and the HSE is engaging with patient and family advocates and establishing the necessary systems. Individual case reviews will begin no later than January 2026 and are expected to take twelve months. The HSE will be writing to families to provide an update and outline next steps for this EEP.

My child had their surgery in a private hospital but under a CHI at Temple Street surgeon, what is the process for me to request a review of my child’s care? 

Please contact the patient feedback and support department of the relevant private hospital where your child was treated.

My child is due to have DDH surgery soon, will they be safe?

Yes. All patients who require DDH surgery currently and in the future are discussed at a cross-hospital, pre-operative, Multi-Disciplinary Team meeting. Experts at this meeting will decide on the best course of treatment for your child.

Staff from many teams attend this meeting and have input into the decision about whether a child should have surgery. Each child proposed for surgery is discussed at this meeting.

What happens next?

The auditor made a number of recommendations, which were fully accepted and are being implemented across CHI and NOHC:

1. All patients in all three hospitals will receive periodic appointments to attend the hospital for assessment until your child’s bones are fully developed (skeletal maturity).
2. A Multi-Disciplinary Team clinical review process has been established to review the relevant cohorts* of patients who underwent surgery in CHI at Temple St and NOHC. We are contacting families to arrange appointments as quickly as possible. The purpose of this review is to assess your child’s hips and ensure they are well.  If any concerns are identified during this appointment, we will discuss them with parents and guardians and recommend a suitable course of action.

*This review does not include children with significant comorbidities as it would not be possible to ensure comparability of outcomes. We encourage parents with children with complex needs, who are worried, to contact your treating medical team to discuss.

3. If any complications are identified during the follow-up reviews they will be acknowledged, discussed with families, and appropriate action will be taken. Families will be involved in a thorough and transparent discussion of decision making, including risks and benefits, in order to make informed decisions for their child.

4. Surgeons across all sites work together and make decisions using shared evidence-based criteria. External experts have been appointed to guide this work, and cross-site multi-disciplinary meetings are in place.

Following the publication of the audit the HSE has commissioned an External Expert Panel (EEP) following the publication of Mr. Simon Thomas’ Independent Medical Audit (DDH Audit). The review will assess the appropriateness of pelvic osteotomy procedures carried out in CHI (Temple Street) and NOHC between January 2010 and March 2025.

The HSE is forming an External Expert Panel (EEP) made up of international clinical experts. These experts will carefully review the original decision to perform your child’s surgery. Preparatory work is underway and the HSE is engaging with patient and family advocates and establishing the necessary systems. Individual case reviews will begin no later than January 2026 and are expected to take twelve months. The HSE will be writing to families to provide an update and outline next steps for this EEP.

Will my child’s surgery be reviewed?

Yes. Every child will be reviewed as part of the HSE EEP which is starting in January 2026.

The review will assess the appropriateness of pelvic osteotomy procedures carried out in CHI (Temple Street) and NOHC between January 2010 and March 2025.

The HSE is forming an External Expert Panel (EEP) made up of international clinical experts. These experts will carefully review the original decision to perform your child’s surgery. Preparatory work is underway and the HSE is engaging with patient and family advocates and establishing the necessary systems. Individual case reviews will begin no later than January 2026 and are expected to take twelve months. The HSE will be writing to families to provide an update and outline next steps for this EEP.

You will be contacted by the relevant hospital in the coming weeks in relation to scheduling your child’s follow-up appointment(s).

However, if you would like further information, please do not hesitate to use the DDH Parent Information Line - Freephone 1800 807 050 (or call 00 353 1 240 8706 from outside Ireland).

Open disclosure concerns:

Families will be involved in a thorough and transparent discussion of decision making, including risks and benefits, in order to make informed decisions for their child.

Any complications identified during the follow-up reviews will be acknowledged, discussed with families, and appropriate action will be taken.

A number of families are contacting us, concerned about an open disclosure process. We understand this is an extremely stressful time and we are working as quickly as possible to see all children impacted by the audit.

The HSE External Expert Panel review will determine if surgery was indicated for each child, and this review is in development by the HSE.

What should I do if I’m worried about my child’s care?

The DDH Parent Information Line is open for families who have queries following this audit’s publication:

Freephone 1800 807 050 (or call 00 353 1 240 8706 from outside Ireland).

Open Monday to Friday 8am to 8pm and Saturday 9am to 5pm.

If you have clinical concerns about your child, please contact your GP or medical team directly.

Can my child be seen soon?

In addition to your intermittent follow-up, you will receive a letter for a multi-disciplinary clinical review in CHI, with oversight from an independent orthopaedic surgeon to ensure your child is doing well.

Will CHI change how DDH is treated going forward?

There are different types of DDH and different types of treatment.

You can find more information and guides to DDH, non-operative treatments, and surgical treatments on www.childrenshealthireland.ie/DDH .

Surgery is one type of treatment. A key recommendation from the audit is now in place, which is the cross-hospital, pre-operative, multi-disciplinary team meeting where each DDH surgical case is discussed. We are working with national and international experts to help guide this process and our continued improvement.

What is CHI doing to prevent varying practices in other areas?

We are working to unify care standards and strengthen clinical governance as part of our full integration into the new National Children’s Hospital Ireland. This includes regular multi-disciplinary meetings, shared decision-making tools, and transparent processes across all hospital sites.

I have questions regarding how CHI processes my child’s personal data. Where can I find information? 

Please see the information provided in the CHI Privacy Policy. Any data protection related queries can be submitted to the DPO via DPO@childrenshealthireland.ie.

For NOHC patients, please see www.nohc.ie.

How can I request a copy of my child’s medical files?

Please see: Healthcare record and personal data requests | Children's Health Ireland.

For NOHC patients, please see www.nohc.ie.

Privacy Information for Callers to the CHI Parent Information Helpline

This helpline is operated on behalf of Children’s Health Ireland (CHI) by HSE Live. When you call, your conversation may be recorded by the HSE for its own training and quality purposes. CHI does not receive or retain the call recordings. The HSE acts as a separate data controller for these recordings.

For more on how your data is used and your rights under GDPR, please see the HSE’s Data Protection Information Notice at https://www.hse.ie/eng/gdpr/dpin/hse-live-phone-dpin.html.

For queries relating to your rights or concerns about your data, you may contact:

CHI DPO at dpo@chi.ie

HSE DPO at dpo@hse.ie

Hip Dysplasia Advocacy Group

Contact: hipdipagireland@gmail.com