In July 2024, Children’s Health Ireland (CHI) and the National Orthopaedic Hospital Cappagh (NOHC) commissioned an audit into Developmental Dysplasia of the Hips (DDH) surgery. The audit was prompted by a protected disclosure raising concerns about a threshold variance for surgery across three hospital sites.
The audit is complete, and a copy of the report can be downloaded here.
CHI and NOHC issued a joint statement on Friday, May 23rd, 2025, which you can view here.
We have endeavoured to compile a list of questions and provide responses to them. These questions will help explain the audit’s findings and recommendations.
1. Why did this audit happen?
The audit was prompted following a protected disclosure, which raised concerns that CHI at Crumlin, CHI at Temple Street and 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.
2. 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 National Orthopaedic Hospital 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 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. No complications were reported at the National Orthopaedic Hospital Cappagh.
3. 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, age, and overall hip development.
4. 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. It is important now that we align surgical decision-making across all sites. Surgeons in CHI at Temple Street and NOHC were using a less-invasive DDH surgical technique.
5. Does this variation mean that some surgeries were unnecessary?
This is not directly answered in the audit. However, As the reviewer indicates in the report (page 15), the high percentage of pelvic osteotomies that do not reach the criteria he used in the review at CHI at Temple Street and NOHC mandates further enquiry. All patients will be reviewed and followed up as per the recommendations (outlined in Question 11).
6. What are the consequences of a child having unnecessary DDH surgery?
This depends on an individual patient’s circumstance. The routine reviews will establish more information for your child and will continue intermittent reviews until your child’s bones are fully developed (skeletal maturity). If you have concerns about your child in this regard, please speak to your medical team about them.
7. 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 this follow-up review to skeletal maturity, these age groups will be used as the framework.
8. 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.
9. 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 will write to these families to confirm this information. These children will then continue in their normal follow up processes, including follow up to skeletal maturity.
10. My child had DDH surgery in CHI at Temple Street or National Orthopaedic Hospital Cappagh, was their surgery necessary?
The HSE will commission a review, which will be undertaken by an external panel of experts, to examine patients who underwent DDH surgery to determine if their surgery was necessary. This will be offered on an opt-in basis, and parents of patients who do not opt-in will have the offer of a HSE-funded appointment with an alternative expert.
11. What happens next?
The auditor made a number of recommendations, which are fully accepted and will be implemented across CHI and NOHC:
- All patients in all three hospitals will receive periodic appointments to attend the hospital for assessment until your child’s bones are fully developed.
- A multidisciplinary team is being established to review the relevant cohorts of patients who underwent surgery in CHI at Temple St and NOHC. This may include radiological assessment with will have oversight from independent Consultant Orthopaedic Surgeons. We will contact families to arrange an appointment. The purpose of this review is to ensure patients are doing well following surgery. Should any concerns be identified during this appointment, we will discuss them with you and recommend a suitable course of action.
- The HSE will commission a review, which will be undertaken by an external panel of experts, to examine patients who underwent DDH surgery to determine if their surgery was necessary. This will be offered on an opt-in basis, and parents of patients who do not opt-in will have the offer of a HSE-funded appointment with an alternative expert.
- Any complications identified during the follow-up reviews 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.
- Surgeons across all sites will work together and make decisions using shared, evidence-based criteria. External experts have been appointed to guide this work, and cross-site multidisciplinary meetings are in place.
12. Will my child’s surgery be reviewed?
- All patients in all three hospitals will receive periodic appointments to attend the hospital for assessment until your child’s bones are fully developed.
- A multidisciplinary team is being established to review the relevant cohorts of patients who underwent surgery in CHI at Temple St and NOHC. This may include radiological assessment with oversight from independent Consultant Orthopaedic Surgeons. We will contact families to arrange an appointment. The purpose of this review is to ensure patients are doing well following surgery. Should any concerns be identified during this appointment, we will discuss them with you and recommend a suitable course of action.
- The HSE will commission a review, which will be undertaken by an external panel of experts, to examine patients who underwent DDH surgery to determine if their surgery was necessary. This will be offered on an opt-in basis, and parents of patients who do not opt-in will have the offer of a HSE-funded appointment with an alternative expert.
13. 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 and Sunday 9am to 5pm.
- Email: cappaghkidsenquiries@nohc.ie
If you have clinical concerns about your child, please contact your GP or medical team directly.
14. Can my child be seen soon?
In addition to your intermittent follow-up, you will receive a letter for a multidisciplinary assessment with oversight from an independent orthopaedic surgeon to ensure your child is doing well.
15. Can I see a different surgeon at my child’s next appointment?
Yes, the option for a second opinion is available to you. You will need to request this when we contact you with your appointment.
16. Will you 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 .
17. 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. This includes regular multidisciplinary meetings, shared decision-making tools, and transparent processes across all hospital sites.
18. I have questions regarding how CHI processes my child’s personal data. Where can I find information?
Any data protection related queries can be submitted to the DPO at: DPO@nohc.ie. To view NOHC’s private statement, click here.
19. How can I request a copy of my child’s medical files?
If you are an NOHC patient you can request your records by emailing mymedicalrecords@nohc.ie
The DDH Parent Information Line is open for families who have queries following this afternoon’s audit publication:
Freephone 1800 807 050 or + 353 1 240 8706 from outside Ireland.`
Phonelines will operate up to 8pm on Friday 23rd May 2025, and thereafter
from 9 am – 5 pm Saturday-Sunday
from 8 am – 8 pm Monday – Friday
Email queries can be sent to: cappaghkidsenquiries@nohc.ie
At Cappagh Kids we treat patients with orthopaedic and musculoskeletal conditions.
What is the Musculoskeletal System?
The musculoskeletal system consists of two main parts:
- The muscular system, which includes the muscles and
- The skeletal system, which includes the bones.
Ligaments, joints, tendons, and cartilage join these parts together. This strong and complex structure helps us stay upright and move around. If any part of this system gets hurt, it can make it hard for us to walk, run, or play. It might even be difficult to do everyday things ourselves, like washing, dressing, or eating. Some musculoskeletal system problems can improve on their own; however, others may need treatment or surgery.
Orthopaedic and Musculoskeletal Conditions
Some of the conditions we treat at the Hospital include:
- Conditions that affect bone growth
- Neurodisability (damage to the area of the brain that controls movement)
- Scoliosis and back abnormalities (curvature of the spine)
- Foot deformities
- Hip dysplasia (malformation of the hip and joint socket)
- Juvenile rheumatoid arthritis (a debilitating inflammatory disease)
- Perthes (rare hip disorder, causing the cells of the upper thigh bone to die)
- Injury caused by trauma
What is a Paediatric Orthopaedic Surgeon?
The word “orthopaedic” means to grow straight. Paediatric Orthopaedic Surgeons are highly trained doctors who specialise in the treatment of young children, working with patients as they grow. Their aim is to correct orthopaedic and musculoskeletal conditions that affect function, growth, and development, treating conditions that are present at birth or caused by an illness or injury.
Consider, if you will, that you are a hero or even a superhero, and that your medical condition is the villain of your story. Just as all superheroes battle to defeat their enemy, you must fight to overcome your challenges, and our army of medics will help you. Visualisation can give you the strength and power to succeed. Think of your treatment as the beginning of an epic journey, and wellness is the destination.
Preparing for Your Hospital Adventure
What to Do?
- Remove nail varnish, piercings and jewellery
- Shower or bathe the night before
- Do not wear fake tan, false eyelashes and false nails of any type.
What to Pack?
Mum and dad can help you to pack, and don’t worry if you forget something. We might be able to help, or a member of your family can bring it in later.
- Pyjamas or nightdress
- Dressing gown
- Slippers (with good grips on the sole to prevent slipping)
- Books for reading and activity books, and if you want to impress your teacher, and outsmart your friends at school, you could pack your school books
- Games and toys, especially your favourite doll or teddy bear
- Toiletries – Toothbrush, shampoo, deodorant
- Mobile phone, charger and earphones so that you can keep in contact with your friends during your stay
- Optional Extra: Emergency treat supplies!
- Superpowers
Last-Minute Questions Anyone?
If you have a question about your surgery that you would like to ask the doctors or nurses, you are welcome to call us at the Hospital on 01 814 0468 between the hours of 9am and 5pm.
Your Adventure Starts Here:
Outpatient Department
Your adventure begins in our Paediatric Outpatient Department. This is a bright and vibrant place, where you will meet members of the Paediatric Team to discuss your medical condition and treatment.
During your appointment, you might undergo a superhero assessment which may include blood tests, xrays and MRI tests.
Radiology
The Radiology department takes pictures of the inside of your body to help the surgeon understand what is going on and plan your treatment. These tests don’t hurt, although the MRI machine can be quite noisy. Mum and dad can stay in the room with you.
Mum, if you are pregnant, please inform the staff or arrange for another adult to stay with your child during the x-ray.
Preoperative Assessment Clinic
If you require surgery, Mum and Dad will complete and return a children’s medical history questionnaire for review by a paediatric anaesthetist. An anaesthesiologist is a doctor who gives special medicines to people so that they can sleep through their surgery and do not feel any pain. You may be invited to attend the hospital for a full superhero preoperative assessment.
At the preoperative assessment, you will meet all of the people who will be looking after you during your Hospital stay. These include a Consultant Anaesthesiologist, Paediatric Nurse, Physiotherapist and Occupational Therapist. They will prepare you for surgery, explain the procedure, discuss your recovery and answer your questions. You may also be asked for blood tests and Xrays on the day.
The assessment can take up to 4 hours, and we recommend that you eat before arriving at the Hospital, and bring a snack and drink with you so that you can don’t lose your superpowers.
Admissions Department
On the day of surgery, you will check-in at the Admissions Department, located at the Hospital Entrance. Your mum and dad will come with you and we will check your details to ensure they are correct, before bringing you to the day ward (day case procedures) or your hospital room (inpatient stay). And don’t forget to pack your superhero Pj’s!
The Day Ward: Day Case Procedures
If you are having a minor procedure and do not require an overnight stay, you will go to the day ward for treatment. You’ll fly through the process and be home in time for tea!
St Pauls Ward: Inpatient Stay
If you require an overnight stay, you will be given a private room with TV and Wifi on St Paul’s Ward and your mum or dad can stay with you. We will take care of you and look after your every need so that you can use your superpowers to heal yourself.
Accommodation for Parents
One parent must remains with a child at all times. As space is limited, we can only accommodate one parent and a charge of €15 per night applies for adult accommodation. Please notify the Ward Manager if you intend to stay at the Hospital.
Meals are available from the Restaurant, at an additional cost. Orders for evening meals can be placed at the Restaurant Monday to Friday before 3 pm. Meals can be eaten in the Vending room before 5 pm, or in the patient’s room thereafter. Weekend meals must be ordered and paid for by 11 am on Saturday.
Physiotherapy & Occupational Therapy Departments
During your stay and following your discharge from the hospital, you may require physiotherapy to improve your range of motion and strengthen your muscles. The Physiotherapy Department will help you improve the part of your body affected by surgery and tell you how you can restore your superpowers.
You might also receive treatment from an Occupational Therapist. They use specialist equipment to help you regain lost skills so that you can be more independent.
Postoperative Care: Outpatient Department
When you are well enough, you can return home to continue your adventure to wellness. You may be invited back to the Outpatient Department to check your progress, remove stitches and casts, clean wounds, apply fresh bandages and ensure your superpowers are fully restored.
Surgery and a hospital stay can be frightening for children and teenagers, and they will look to you for reassurance. If you prepare your child in advance, they are likely to have a positive hospital experience which will benefit their recovery.
- Tell your child that he/she is coming to the Hospital
- Read stories about hospitals to them, and play doctors and nurses
- Explain why they are attending and always connect the reason with a positive outcome
- Invole your child in the preparation and packing, and be sure to include comfort toys, blankets and other items to put them at ease
- If you are caught off guard by a question, defer answering it until you are comfortable and confident to do so, otherwise they will sense your discomfort and this may make them anxious
- Always tell the truth. A child may require blood tests or x-rays. Explain the reason for the test, what is involved and how the test will benefit their treatment
- Stay with your child at all times during their Hospital stay. If you have to leave the room for a short period, let them know when you will return. If you are leaving the hospital for a period, please arrange for another adult to keep your child company until you return
Children First is for everyone.
The focus of Children First: National Guidance for the Protection and Welfare of Children 2017 “is to help a general audience recognise child abuse and report a reasonable concern about a child’s welfare or protection. It also contains specific information about the statutory responsibilities of individuals who are mandated to report child protection concerns and of organisations that provide relevant services to children.”
Click here to view NOHC Children First Policy.
“When you decide not to be afraid you can find friends in super unexpected places”
Ms Marvel
Anaesthetist
A doctor that is trained to give special medications to patients so they can sleep through surgery and don’t feel any pain.
Biopsy
Doctors take a small sample of tissue from your body and examine it under a powerful microscope
Cannula
A thin tube that goes into your vein, ususally in your hand or at the elbow, which can be used to transport medicine into the blood stream or to remove fluid from the body
Cartilage
A connective tissue that covers and protects long bones at the joints
ECG – Electrocardiogram
A machine that measures the electrical activity around the heart through stickers which are placed on the chest
Femeral Head
The top of the femur bone (large thigh bone)
Fixator
A frame used in limb lengthening and reconstruction to encourage bone growth
HDU – High Dependency Unit
A special ward dedicated to patients who require extra care and attention following surgery
IV Line – Intravenous Line
A tube inserted into the vein to bring medicine and fluids into the bloodstream
Joint
The place where 2 bones come together to allow movement, e.g. wrist, elbow, ankle, hip, shoulder
Key Hole Surgery
Surgery that is carried out through a small cut or incision in the skin
Ligament
A band of tissue that connects one bone to another to form a joint
MRI – Magnetic Resonance Imaging
A large machine that is used to take pictures of the inside of your body
The Musculoskeletal System
2 systems, the muscular system and the skeletal system, that work together to give us our shape and stability, and enable us to move. These 2 systems are connected by joints, ligaments, tendons and cartilage.
Necrosis
Dead tissue and bone cells
Occupational Therapist
A person who helps people to recover after an injury, illness or surgery. Occupational therapsits help patients to do everyday tasks for themselves, like making a cup of tea, bathing and dressing
Orthopaedic Surgeon
A highly skilled surgeon who treats patients with musculoskeletal conditions that affect the bones, muscles, joints, ligaments, tendons and cartilage.
Osteotomy
A surgical cut to the bone
Perthes
A rare childhood condition of the hip. The blood supply becomes interrupted for reasons unknown, causing the femeral head bone to die.
Pharmacist
A person who is an expert on medicine
Phlebotomist
A person who takes blood samples for testing
Physiotherapist
A person who helps you to return to activity following surgery or an injury
Regression
Sometimes patients can experience a set-back in their recovery. This is known as a regression.
Sepsis
An infection in the blood stream
Tendon
A strong, flexible cord that attaches the muscle to the bone
LILY’S STORY
When Lily, a fun-loving eight-year-old girl from Cork, found a lump on her shoulder, her GP immediately sent her to the local hospital for a CT Scan. The results revealed a low-grade sarcoma, which is a cancerous tumour that originates in the bone and soft tissue. It was a very frightening and emotional time for Lily and her family.
Lily was referred to the National Orthopaedic Hospital Cappagh for treatment. The Hospital is home to the National Sarcoma Centre and has the greatest concentration of orthopaedic expertise in Ireland. Our Consultants specialise in the treatment of bone and soft tissue tumours.
We knew this family needed a lot of care and support. They were miles from home and coping with a shock diagnosis. As for Lily, at 8 years can struggle to understand the conversation, especially when medical terms are used, but she could sense the fear.
Our multi-disciplinary team of Paediatric Orthopaedic Consultants, nurses, and allied health and social care workers rallied around the family to help them through this difficult time. We explained the surgery in simple terms and offered emotional and practical support to Lily, and her mum and dad.
“The staff at Cappagh took us through each step of what was required for surgery – this was of great comfort to us as we knew she was in good hands“. Rita, Lily’s Mum
We are delighted to report that the tumour and tissue margins were successfully removed in surgery. And following treatment, Lily returned to school and her fun-filled life six weeks later.
“Everything, from the moment we went to Cappagh was taken care of. They were our support system throughout that time and we cannot thank them enough” JOHN, LILY’S DAD
AOIFE’S STORY
Former professional footballer and current assistant coach of Shamrock Rovers, Glenn Cronin, is no stranger to the National Orthopaedic Hospital Cappagh. He received regular treatment for sports-related injuries throughout a long and successful career. When he retired, he thought he’d seen the last of the Hospital.
“I had a lot of injuries. The treatment in Cappagh was always top-class. The people were always really professional and reassuring.”
However, in 2016, while holidaying with his family in Spain, Glenn’s 9-year-old daughter Aoife announced that she had an extra bone in her arm. On checking it, Glenn and his wife Emma discovered a lump and fear began to grip them.
Returning to Ireland, they wasted no time. Aoife came to the hospital for an x-ray, MRI and biopsy, and a week later, Mr Gary O’Toole, Orthopaedic Surgeon, removed her “extra bone”. Following laboratory analysis, the families worst fears were confirmed. The resected tumour was cancerous.
When a cancerous diagnosis is confirmed, fear envelopes the family and the patient, parents, and siblings react in their unique way. We understand the many emotions that surface in the wake of a shocking diagnosis. The Hospital’s medical excellence is complemented by genuine and empathic care and our multi-disciplinary team unite to offer support and care for each family member.
We helped Aoife, Glenn, Emma and her brother through this challenging time.
Since the surgery, we are delighted to report that Aoife has made a remarkable recovery and continues to go from strength to strength.
SARA’S STORY
When Sara Kelly consulted her GP in 2011 for a chest infection, she was surprised to learn that she was living with scoliosis, a condition that causes curvature of the spine in adolescents.
Sara was referred to Crumlin Hospital for regular check-ups to monitor the disease progression, and shortly after that, when the condition began to impact her life negatively, Sara elected for surgery. Three years on, the former under-14 Meath camogie player remained on the surgical waiting list.
In 2015, Sara was one of 5 patients transferred to the waiting list at National Orthopaedic Hospital Cappagh, and within five months she underwent spinal correction surgery. Two rods and 14 screws were inserted into Sara’s back to correct the curvature. The Hospital has an incredible Paediatric Orthopaedic Department committed to improving access to treatment and delivering better outcomes for young patients. Sara’s surgery was a great success.
“I gained 3 to 4 inches in height during my scoliosis surgery, and I’m no longer in pain. The recovery was tough but manageable, and I was home from the hospital after six days. I am living pain-free. Surgery has changed my life.”