Case Study – Orthopaedics: Wrong Site Surgery

Case Study – Orthopaedics: Wrong Site Surgery



A 72-year-old male patient was consented for a total right knee replacement by a consultant orthopaedic surgeon in the private sector. The consent process took place six weeks prior to surgery, during an outpatient consultation. The patient was provided with an information leaflet regarding the procedure, its corresponding risks and benefits. He was encouraged to read through the information provided, reflect on the discussion, ask any supplementary questions and confirm if he was happy to proceed with the surgery.

The patient contacted the consultant to say that he was minded to proceed with surgery. However, he wanted confirmation that the risks of failure on the right knee were minimal (0.5 – 1% year-on-year and 5% ten years post-operatively), given that he knew his left leg was weakened due to an old sporting injury combined with clinical findings. These conditions indicated that a below knee amputation of the left leg was likely in the near future (5 – 10 years). The consultant confirmed that the issues with the left leg were separate and there were no clinical indicators to show he was at increased risk of failure in the right knee.

The procedure was listed and the patient attended the private hospital on the day of surgery as advised. On arrival, he was informed that his consultant (A) was unavailable due to ill health; however, another consultant (B) had been requested to undertake the surgery. He was introduced to the new consultant and advised that he could cancel the procedure if he preferred. However, consultant B was unclear when surgery could be re-listed (surgery had already been cancelled nine weeks previously due to the patient being unwell). The patient decided to proceed and consultant B re-consented the patient for total knee replacement prior to taking him to surgery. He also marked up the knee he intended to operate on – the LEFT knee. The patient thought it odd but did not raise his concern, assuming that this was part of the process and also believing what he had been told, that consultant B had discussed his procedure with consultant A.

Surgery proceeded on the left knee. Sadly, complications ensued due to the pre-existing clinical deterioration of the patient’s left leg. Despite efforts to save the leg, consultant B had little choice but to proceed with an above knee amputation and the total knee replacement was abandoned.

Post-operatively, it became apparent that whilst consultant B did have a telephone conversation with consultant A prior to the surgery, the discussion was brief. Consultant B was advised to review the patient’s notes and specifically, a drawing outlining the proposed surgery and site location. The drawing incorrectly identified the left knee as the site of operation. If consultant B had reviewed the patient’s records, he would have noted that all discussions related to the right knee. However, he had not done so on the basis that he had been advised that there were no contra-indications to surgery; the patient had consented and the operation site had been documented via a drawing in the notes.

The patient confirmed post-operatively that he did not raise any objections to consultant B drawing on his left knee because he trusted his clinician and knew there was a drawing in his medical records that would guide consultant B. It was also determined through witness evidence, at a later stage, that the patient was of a generation where “doctor knows best” and would not feel comfortable questioning the consultant.

Evidence confirmed amputation would have been necessary within five years in any event, albeit it would be a below knee not above knee amputation. The claim related to wrong site surgery and acceleration/need and complexity of amputation.

Learning Points

This case highlights several learning points for consideration when managing patients.

Record keeping

On review, it was considered the medical records were generally in good order. The reasons for surgery, the risks and benefits and the consent process were all clearly documented. The crucial error throughout the notes related to the drawing of the operation site consistently on the left knee. It transpired, in evidence, that the first drawing was done incorrectly (consultant A could not account for this save for human error) and thereafter (repeated three times in the notes). The first drawing had been copied and the error was simply missed and therefore not corrected. Consultant A felt this may have been due to time pressures, but in reality, had no explanation for the error being repeated. Experts held that the failure to correctly identify the operation site in the clinical notes was evidence that the care given fell below a reasonable standard and ultimately led to surgery on the wrong leg.

It is easy to simply repeat what is detailed in notes without seeing the error when it comes to written records. Allocate sufficient time to review medical records and any associated documents to identify errors and correct them. This is particularly important in situations where you are taking over the care of a patient from a colleague.


It was alleged that the patient did not provide informed consent as he did not truly understand the risks of surgery on the right knee and how it would impact his life if it were unsuccessful. It was alleged that the initial consent process stated that the patient had no comorbidities or contraindications to surgery on his right knee, which he argued was incorrect. He argued that given the left leg was always subject to amputation in the near future, the impact on his day-to-day living if the right knee replacement failed would be significant.

As a question of fact, the court found that both consultants A and B had failed to obtain informed consent, agreeing with the patient that the impact of the right knee replacement, if it had gone badly, were not discussed or taken seriously enough, despite the patient being concerned and making his concern known from the outset. An expert appointed for consultant A, agreed with the Court and the Claimant’s expert’s findings. However, an expert appointed for consultant B argued in his evidence that given he believed informed consent had previously been obtained, he could not be held accountable when he failed to highlight the risk. Issues with the left leg were not brought to his attention in the first place and he was relying on the drawing as advised.

The Court did not accept that this was a reasonable standard of care and considered that consultant B should have taken a more detailed and thorough approach to reviewing the notes and familiarising himself with the patient, having agreed to assume responsibility for the surgery.

In the post Montgomery world, informed consent is not truly obtained unless you understand the patient’s needs, concerns and the potential impact of a particular treatment option. The comorbidity, in this case, was a weakened left leg, prime for amputation, and a failure to understand that if the right knee replacement failed, the patient could effectively become wheelchair bound.

In addition, if you agree to accept responsibility for the care of another consultant’s patients, it is essential that you review the notes thoroughly and consent the patient yourself, to a point at which you are satisfied that they understand all the risks and benefits and have given you informed consent. You cannot rely on a colleagues assurances that informed consent has been obtained. Please refer to GMC’s guidance, Decision making and consent 2020.


It was accepted that consultant A failed to exercise a reasonable standard of care when handing over the patient to consultant B. Specifically, consultant A accepted that he had failed to discuss which knee was to be operated upon and further did not highlight the issues with the left leg and the fact that it would clinically require amputation in the next 5 – 10 years. Consultant A accepted that there were specific issues relevant to the patient regarding why failure of the right knee replacement would be catastrophic to his daily living and these should have been highlighted to consultant B.

Consultant B’s evidence outlined that had he known of the issues with the left leg, he would never have agreed to stand in for consultant A and would simply have cancelled the surgery allowing consultant A to perform the operation at a future date.

The Court held that consultant A had failed to provide relevant information. In addition, they held that consultant B failed to read the clinical notes and check the correct operation site. The Court accepted that had he done so, he would have identified the increased risks associated with the surgery, and on balance, would not have proceeded with the surgery, thus avoiding the injury that ensued. The Court found both consultants to be liable, as the care provided by both fell short of the standard of care reasonably to be expected of professionals with their expertise. Furthermore, the Court held that neither consultant A or B could rely on the actions of the other to negate their own responsibility.

If you are required to handover a patient to a colleague, ensure you have sufficient time to alert them of all issues in respect of that patient’s care. Remember, you will retain responsibility for the outcome if you fail to highlight something which would have altered the patient outcome. In this case, consultant B felt he had been misled by consultant A and therefore should not be accountable for the errors caused by consultant A. However, the law does not allow clinical staff to rely on another’s negligence to negate their own responsibility. In order to have no liability in such circumstances, the actions of the other party must be so significant as to break the chain of causation and thus void the liability of another party. In circumstances where the handover could have avoided a negative outcome, which was reasonably foreseeable, then liability to some degree will remain with both parties.

Therefore, if you are receiving a patient, ensure you have taken sufficient time to review all the available information and that you are happy to proceed based on the information you have been able to gather. If you are unsure whether you have all the information and the situation is not an emergency, do not proceed.

Patient sensibilities

The Claimant’s expert alleged that both consultants failed to appreciate that the patient was of a generation who would ultimately consider that “doctor knows best” and would not seek to challenge the care provided. This issue was raised as a defence to the argument that the patient could have stopped the error by confirming the correct knee for surgery and questioning why consultant B was drawing on his left knee and not his right in the pre-operative period. The expert for consultant A did not comment on this line of reasoning, but the expert for consultant B stated that if the patient was of the view that “doctor knows best”, he would not have questioned consultant A regarding the risks of total knee replacement failure. Ultimately, the Court did not make a finding on this issue on the basis that the claim had been successfully established on other grounds.

It is important to understand the sensibilities of your patient in order to obtain informed consent and to understand how best to manage the patient/doctor experience. There are patients who will defer to the knowledge of the doctor and those who will question every aspect of their care. Understanding who your patient is and how they think and respond to a doctor’s authority is key to developing a good patient/doctor relationship and reducing the likelihood of complaints/claims.

Reviewed and updated February 2024

Originally published January 2022

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. We recommend that you seek independent legal and/or professional advice in relation to your legal or medical obligations or rights. Premium Medical Protection Limited is the owner of this material and its contents are protected by copyright law © 2022. All such rights are reserved.

For more information regarding the hyperlinks referenced in this document, click here