After a lengthy wait, the report from Great Ormond Street Hospital following review of care provided to 789 of its patients has now been published. The report, which can be read in full via this link GOSH_Patient_Recall_Findings_within_the_Lower_Limb_Lengthening_and_Reconstruct_KheSaiK.pdf, sadly confirms the serious concerns previously raised about Mr Yaser Jabbar and finds that the standard of care received by many patients fell far below the standard which they were reasonably entitled to expect.

The review involved assessment of whether physical and/or psychological harm was caused to the patients and if so, the level of harm (graded as low/mild harm, moderate harm and severe harm). There was consideration of 7 areas of care, these being:

• Record keeping and documentation;
• Assessment, including history, examination, and diagnosis;
• Investigations and imaging;
• Consent process;
• Decision-making and case selection;
• Surgical skill and technique;
• Identification, management, and ownership of complications.

The independent experts involved found inconsistencies in the approach taken across the board and also a number of recurring problems. This includes:

• Incomplete or unclear patient records,
• Consent discussions not always being fully recorded.
• Assessments being brief or key information missing.
• Decisions about surgery not being well documented
• Alternative treatment options not being explained clearly
• Complications not being recognised or acted on quickly enough.

Of the patients reviewed, 98 had suffered some level of harm (amount to 12.4%) and 94 of these were specifically linked to care provided by Mr Jabbar. The 94 patients included 19 with mild harm, 39 with moderate harm and 36 with severe harm and there was a higher rate of patients under the surgical pathway who suffered harm compared to a non-surgical pathway. The actual number may in fact be higher, as there were 53 further patients, in respect of which there was insufficient information available to make an informed decision on the level of harm.

Of the 98 patients who suffered harm, 4 of the patients had suffered harm that was not attributable to Mr Jabbar. For 3 of these patients, the harm caused was due to another Surgeon, who also no longer works at GOSH. The other patient came to harm due to being lost to follow up, which means that they did not receive a timely clinical follow up.