"I was deeply upset with the result of young [the toddler's] care and I will carry that with me. I hope that despite his protracted treatment, [the toddler] still has a good outcome for his future," the surgeon said.
It is not clear in the report if the toddler suffered any long-term damage from the delay.
On October 2017, the toddler was diagnosed with a dislocated left hip which needed surgical intervention to repair.
The HDC report says that after the surgery, which took place in November 2017, no CT scan was undertaken.
Between December 2017 and September 2018, multiple X-rays were performed and the surgeon examined the progress himself.
"During this time we experienced frustration and stress relating to the X-ray process where the X-ray clinicians had little knowledge about the condition and when we would present to [the surgeon] he told us that he cannot tell us anything definitive as the X-rays were of poor quality."
The surgeon assured the toddler's mum that all these things were normal, the report said.
It wasn't until October 2018 that a junior orthopaedic surgeon noticed that the toddler's left ankle had limited movement and he lurched to the right that the re-dislocation was finally picked up.
The toddler was referred to a paediatric orthopaedic surgeon at another hospital for further management. He had to undergo further surgery in February 2019 and remained in a cast for another four months.
The report said he progressed well.
The toddler's mum said the surgeon needed to slow down his consultations, listen to caregivers' concerns and learn not to provide empty reassurances everything would be "okay" without clear evidence.
"And discuss further treatment options with parents if they raise concerns about their child's lack of progress or the monitoring process," she told HDC.
"It was only once I talked to my son's GP and asked her to speak directly to the surgeon that our concerns appear to have been taken seriously."
The orthopaedic surgeon and Northland DHB were found in breach of the Code of Health and Disability Services Consumers' Rights for failures in their care of a toddler following surgery.
Kevin Allan, Deputy Health and Disability Commissioner, said the report highlighted the importance of clinicians interpreting X-rays correctly, reading radiologists' reports and investigating concerning clinical features.
"All of these factors should have prompted the surgeon to investigate the toddler's hip further."
The Deputy Commissioner found that the DHB had no policy in place to require a CT scan after surgery for developmental dysplasia of the hip. They also had no reliable system to check that orthopaedic surgeon had read and approved a radiologist's report.
He recommended the DHB undertake an audit of developmental dysplasia of the hip surgery on children over the last 12 months, and ensure all children had a scan and were seen in a consultant clinic until stable.
Allan was satisfied that the orthopaedic surgeon has taken appropriate steps to improve his practice since these events and that both the surgeon and the DHB had provided a written apology to the toddler's family.
Teen given wrong medication
In another HDC decision released today, a pharmacist dispensed a teenage girl suffering from migraines with the wrong medication.
While the teenager was prescribed sumatriptan, the pharmacist mistakenly dispensed a antidepressant called sertraline, which is used to treat depression, obsessive compulsive disorder, panic attacks, anxiety or post-traumatic stress disorder.
The error was discovered over six months later by the teenager's school nurse.
Now, the teenager struggles to take her migraine medication out of fear it being the wrong pills.
The pharmacy and the pharmacist were found in breach of the Code of Health and Disability Services Consumers' Rights for the failures.
A number of recommendations were made by the Deputy Commissioner to the pharmacy, including that it provide a formal written apology to the teenager's mother and outlining actions it had taken to prevent such an error happening again.
