BOA Statement to HSIB Report into the implantation of wrong prostheses during joint replacement surgery

21 Jun 2018

The BOA has released a response to the Healthcare Safety investigation Branch (HSIB) report into an incident of a wrong prosthesis implanted during a joint replacement procedure in 2017.  The full statement is below:


The British Orthopaedic Association welcomes the report by the Healthcare Safety Investigation Branch (HSIB) into an incident of a wrong prosthesis implanted during a joint replacement procedure in 2017.

The report makes a number of recommendations to improve procedures to lessen the likelihood of this type of incident, deemed a ‘Never Event’*, from occurring in the future. The BOA supports the recommendations made in the report and hopes these suggested improvements will produce positive results.

BOA President Ananda Nanu contributed to the HSIB review process and commented on the publication of the report that “While Never Events are very rare, we recognise that each one represents an incident that should not have  Happened, and have adverse consequences for patients. This case highlights the anxiety and distress caused to the particular patient affected. As a profession we must continue to pursue measures to avoid and eliminate them in future.”

While the HSIB report focusses on one individual incident, it also states that the number of Never Events involving a wrong implant has not declined since reporting began in 2011, with an average of 52 per year across all surgical procedure types. As such, the BOA welcomes all efforts to improve patient safety and to encourage development of further mechanisms for detecting and flagging issues with wrong implants.

If you have any comments on this issue, please contact

*’Never Events’ are described by NHS Improvement in their policy and framework document as ‘Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

The BOA’s previous position statement on the issue of Never Events was published on 7 September 2017 and is available here and in our knowledge hub.


Policy position statements