British Orthopaedic Association

Private and voluntary organisations · Registered charity

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First report 21 Jan 2025•Latest report 21 Jan 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
300%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
10

Described in responses

Concerns and recipient responses

Statements from British Orthopaedic Association linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Dorset

    AI-generated summary

    Reginald Victor Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Reginald Victor Smith suffered a witnessed fall at his care home and underwent surgery for a fractured neck of femur. After failure of the metalwork, he underwent revision surgery, received palliative care, and died in hospital on 7 December 2023. Concerns included the possible loosening or deformation of a repeatedly used surgical jig, its loss while sent for manufacturer analysis, and the absence of quality control or auditing of jig integrity before surgery.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Orthopaedic Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of auditing and spot checks of surgical jig integrity

    Wider context from the report

    “2) I have concerns with regard to the following: i) Each jig is used many times in surgery having been sterilised after each procedure. It is hammered into the thigh bone and on this occasion may have become deformed over time. ii) The jig was sent away to the manufacturer for analysis but was lost and so no information was available to the court in relation to its integrity. iii) There is no quality control in place in relation to the examination of the jigs being used (other than when it is assembled in theatre by a nurse) prior to surgery. There is no auditing/ spot checks in relation to the integrity of the jigs. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Orthopaedic Association; that does not assign responsibility.

    PFD Monitor interpretation

    Potential deformation of repeatedly used surgical jigs

    Wider context from the report

    “2) I have concerns with regard to the following: i) Each jig is used many times in surgery having been sterilised after each procedure. It is hammered into the thigh bone and on this occasion may have become deformed over time. ii) The jig was sent away to the manufacturer for analysis but was lost and so no information was available to the court in relation to its integrity. iii) There is no quality control in place in relation to the examination of the jigs being used (other than when it is assembled in theatre by a nurse) prior to surgery. There is no auditing/ spot checks in relation to the integrity of the jigs. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Orthopaedic Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of preoperative examination of surgical jigs

    Wider context from the report

    “2) I have concerns with regard to the following: i) Each jig is used many times in surgery having been sterilised after each procedure. It is hammered into the thigh bone and on this occasion may have become deformed over time. ii) The jig was sent away to the manufacturer for analysis but was lost and so no information was available to the court in relation to its integrity. iii) There is no quality control in place in relation to the examination of the jigs being used (other than when it is assembled in theatre by a nurse) prior to surgery. There is no auditing/ spot checks in relation to the integrity of the jigs. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete review and publish generic guidance on checking jig condition and preparation, and following implant operative-technique documentation.

    Verbatim wording from the response

    “The BOA has drafted generic advice for trauma and orthopaedic surgeons on the need for vigilance as to the condition and preparation of any jig used, as well as adherence to the operative technique documentation accompanying each implant.”

    Source location

    Response from British Orthopaedic Association
    Page 2 · response
    Published 21 January 2025

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026