NHS mix-up sees woman accidentally undergo 'invasive' gynaecological procedure

·2-min read
Photo credit: Keith Brofsky - Getty Images
Photo credit: Keith Brofsky - Getty Images

A woman underwent an invasive gynaecological procedure, instead of fertility treatment, after an NHS error left her confused with another patient, says a newly issued safety report. It's believed that the two women had similar sounding names, but that medical staff missed ample opportunities to correct the mistake in the run-up to the operation.

According to report from the BBC, the 39-year old female patient (Patient A) visited a gynaecology outpatient department for her initial fertility appointment in July 2019, accompanied by her sister.

It's thought that Patient A was checked in at the reception desk (as is standard practice) at the same time as another patient (Patient B), who had arrived for a colposcopy appointment. Such a procedure is carried out in order for doctors to take a closer look at the cervix, the lower part of the womb at the top of the vagina, often after a routine smear test has identified abnormal cells in the cervix.

A nurse then repeatedly called Patient B's name in the waiting room with no response, before trying only her first name. Patient A, whose surname sounds similar to Patient B's first name, then mistakenly believed she was being ushered into the clinic room.

Photo credit: Nenov - Getty Images
Photo credit: Nenov - Getty Images

Continued misunderstandings then failed to identify the name mix-up, resulting in Patient A incorrectly being given a colposcopy. "[During a routine colposcopy] first, the gynaecologist will talk to you about the reason you are there, and what will happen," Dr Clare Morrison, a GP and Medical Advisor at Medexpress, previously told Cosmopolitan. "Then you will lie on the couch, and the Gynaecologist will insert a special speculum or 'colposcope' into the vagina."

Dr Morrison adds, "They will use a microscope to look closely at the cervix. They may spray a liquid, such as dilute acetic acid, onto the cervix, so abnormalities show up better... If necessary, tissue may be removed, known as 'punch biopsies', to analyse the problem further." The procedure shouldn't be painful and local anaesthetic may be administered before a biopsy or LLETZ, to minimise any discomfort.

Patient A was telephoned by the clinic while on her way home and informed of the mistake.

Staff from the hospital later issued an apology to Patient A, who did go on to have her original fertility appointment in the end, but was said to be left extremely distressed by the whole incident.

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