Months of pain after wrong hip component implanted
BBCA woman from Cornwall who had the wrong component surgically implanted during a hip replacement operation said the mistake caused her months of pain and inconvenience.
Mandy Dossett, from Rosecare, near Crackington Haven, Cornwall, was forced to undergo the procedure twice at North Devon District Hospital in 2023 and 2024 due to the error.
The Royal Devon University Healthcare NHS Foundation trust, which apologised, described it as a "never event". However, such incidents have quadrupled at the trust, according to the latest figures.
The trust said: "We take patient safety very seriously, and we review any never event fully in line with NHS guidance."
Dossett, 55, was working as a chef when arthritis started to cause her problems in her hip.
It became so painful that she sought help from her GP, who referred her to her closest hospital.
North Devon District Hospital scheduled a hip replacement in December 2023 but the procedure did not go to plan.
Dossett said: "I had a phone call just before Christmas. They said: 'You need to have it done again because we put the wrong size things in.'"
Somehow parts of the artificial hip that had been implanted were different sizes.
"You'd think they'd come as a set on the shelf... apparently not. But three people should have checked before it went in me," Dossett said.
Litigation solicitor Michael Blakemore-Carson said: "If you imagine the hip is a ball and socket joint... so the femoral head is the ball, and the socket that it goes into, they're supposed to be the same size.
"But, in Mandy's case, the mistake that was made was that the ball was too small. It was smaller than the socket and the liner".
The mismatched components were not spotted by the hospital despite an X-ray after the procedure.
Dossett said: "Someone should have checked it when it came off the shelf, and then someone was meant to check it before the surgeon.
"Then the surgeon should have checked before he actually put it in, so it should never have happened.
"The part was 2mm too small, which doesn't sound a lot, but it's a lot when it's rattling around."
The mistake was discovered by the National Joint Registry, which tracks joint replacement surgeries across the country.
The clinical database informed the hospital that the barcodes for the boxes that had held the hip replacement components did not match.
That information triggered the never event alert - a serious patient safety incident that is considered preventable.
Never events increasing
The Royal Devon trust, which also operates North Devon District Hospital, apologised to Dossett, but did not explain what went wrong.
The most recent NHS statistics showed never events were on the rise - generally across the NHS - but also at the Devon trust.
Dossett's operation was at the end of 2023, and the figures from that period to the most recent showed never events had quadrupled at the trust at one stage.
In 2023-2024, there was one never event, two for the following financial year (2024-25) and, most recently, eight were recorded for 2025-2026.
Blakemore-Carson said: "Thankfully these incidents are rare, but we would hope that there's an investigation and things change.
"It could be just really as simple as somebody reading out the barcodes of boxes in surgery and checking that they match."
The hospital trust said: "The majority of these past events resulted in low or no harm and we have responded proportionately to investigate each one.
"Learning from our reviews is shared with our Patient Safety Committee and cascaded through our services to minimise these events in the future."
Mandy DossettDossett had to have a second hip replacement the following year to correct the first procedure.
She said the mistake delayed her recovery and return to work, leaving her struggling financially, as well as in pain and being inconvenienced.
She said: "I had to get friends and family to help. I couldn't drive, couldn't clean, couldn't do much for myself. It was a lot to ask of people.
"I was also a chef at the time, and I couldn't go back to that role. It cost me a lot."
She is now working in a local shop, feeling much stronger and delighted to put the episode behind her.
However, she said some reminders remained: "It's left me with a big scar that I didn't have before. The first time it was just a nice straight line, and now... it's not good.
"But I'm grateful I was healthy to start with. If I was an older person, having to do two operations, it would be a lot for an older person to go through twice."
She said she had also been warned by her orthopaedic surgeon that there was a greater chance that the second hip could fail earlier than usual.
The hospital trust settled with Dossett out of court and paid her compensation.
