London Daily

Focus on the big picture.
Thursday, Jul 03, 2025

Wrong woman given invasive procedure among NHS mixups

Wrong woman given invasive procedure among NHS mixups

Watchdog reports scores of cases of procedures being performed on wrong patient or wrong part of body
A woman was given an invasive gynaecological procedure after being mistaken for another patient, a health watchdog has revealed as it warned that more must be done to prevent waiting room mixups.

The Healthcare Safety Investigation Branch (HSIB) said such cases were “not isolated” but not widely reported and could lead to physical and psychological harm.

The error was one of 472 serious healthcare incidents reported in England in 2019-20, the HSIB said in a report, nearly half of which were procedures performed on the wrong patient or on the wrong part of the body.

It said a better system of safety measures was needed to make sure patients are not mixed up and given the wrong procedure during outpatient appointments, and it called for the NHS to review patient identification schemes in outpatient settings.

The 30-year-old woman received a colposcopy meant for another patient instead of the fertility treatment assessment she was meant to have after attending a gynaecology outpatient clinic for her first fertility appointment in July 2019. She checked in with reception at the same time as another patient arriving for a colposcopy, a procedure to look at the cervix.

The nurse called out the second patient’s name several times with no response, then just her first name, which sounded like the first patient’s surname. The woman thought the nurse was calling for her. No other checks were conducted to confirm her identity, and after several further misunderstandings she was wrongly given the invasive procedure.

The error was only realised after the patient had left the clinic. Staff phoned her on her way home to tell her what had happened and apologise. “The patient told us she was so distressed after the incident that she did not want to pursue her fertility treatment,” said Dr Sean Weaver, deputy medical director at HSIB. She eventually went on to have her fertility appointment.

“Any invasive procedure carried out incorrectly has the potential to lead to serious physical and psychological harm and erode trust in the NHS,” Weaver said.

The report said there were no formal safety controls to manage the risks that can arise when patients have similar names and several clinics are running at the same time in a department.

With many patients waiting in the same area, this can “affect the risk of the wrong patient being selected”, the HSIB said, with factors such as workloads and time pressures on staff possibly reducing the level of safety checks carried out.

Weaver said: “It was important to explore this patient safety risk at the system level, especially as invasive procedures being done in outpatient settings continue to increase, even without any changes that might be brought about due to the Covid pandemic.

“The safety recommendation we have made is there to encourage cohesive and effective changes at a national level, to reduce the risk of misidentification, and ensure the right patient receives the right procedure.”

A spokesperson for the NHS in England said: “These events are fortunately extremely rare and the NHS is currently undertaking its own review of incidents as hospitals rightly continue to prioritise patient safety.”
Newsletter

Related Articles

0:00
0:00
Close
DJI Launches Heavy-Duty Coaxial Quadcopter with 80 kg Lift Capacity
U.S. Senate Approves Major Legislation Dubbed the 'Big Beautiful Bill'
Largest Healthcare Fraud Takedown in U.S. History Announced by DOJ
Poland Implements Border Checks Amid Growing Migration Tensions
Political Dispute Escalates Between Trump and Musk
Emirates Airline Expands Market Share with New $20 Million Campaign
Amazon Reaches Milestone with Deployment of One Millionth Robot
US Senate Votes to Remove AI Regulation Moratorium from Domestic Policy Bill
Yulia Putintseva Calls for Spectator Ejection at Wimbledon Over Safety Concerns
Jury Deliberations in Diddy Trial Yield Partial Verdict in Serious Criminal Charges
House Oversight Committee Subpoenas Former Jill Biden Aide Amid Investigation into Alleged Concealment of President Biden's Cognitive Health
King Charles Plans Significant Role for Prince Harry in Coronation
Two Chinese Nationals Arrested for Espionage Activities Against U.S. Navy
Amazon Reaches Major Automation Milestone with Over One Million Robots
Extreme Heat Wave Sweeps Across Europe, Hitting Record Temperatures
Meta Announces Formation of Ambitious AI Unit, Meta Superintelligence Labs
Robots Compete in Football Tournament in China Amid Injuries
Trump Administration Considers Withdrawal of Funding for Hospitals Providing Gender Treatment to Minors
Texas Enacts Law Allowing Gold and Silver Transactions
China Unveils Miniature Insect-Like Surveillance Drone
OpenAI Secures Multimillion-Dollar AI Contracts with Pentagon, India, and Grab
Marc Marquez Claims Victory at Dutch Grand Prix Amidst Family Misfortune
Germany Votes to Suspend Family Reunification for Asylum Seekers
Elon Musk Critiques Senate Budget Proposal Over Job Losses and Strategic Risks
Los Angeles Riots ended with Federal Investigations into Funding
Budapest Pride Parade Draws 200,000 Participants Amid Government Ban
Southern Europe Experiences Extreme Heat
Xiaomi's YU7 SUV Launch Garners Record Pre-Orders Amid Market Challenges
Jeff Bezos and Lauren Sanchez's Lavish Wedding in Venice
Russia Launches Largest Air Assault on Ukraine Since Invasion
Education Secretary Announces Overhaul of Complaints System Amid Rising Parental Grievances
Massive Anti-Government Protests Erupt in Belgrade
Trump Ends Trade Talks with Canada Over Digital Services Tax
UK Government Softens Welfare Reform Plans Amid Labour Party Rebellion
Labour Faces Rebellion Over Disability Benefit Reforms Ahead of Key Vote
Jeff Bezos and Lauren Sánchez Host Lavish Wedding in Venice Amid Protests
Trump Asserts Readiness for Further Strikes on Iran Amid Nuclear Tensions
North Korea to Open New Beach Resort to Boost Tourism Economy
UK Labour Party Faces Internal Tensions Over Welfare Reforms
Andrew Cuomo Hints at Potential November Comeback Amid Democratic Primary Results
Curtis Sliwa Champions His Vision for New York City Amid Rising Crime Concerns
Federal Reserve Proposes Changes to Capital Rule Affecting Major Banks
EU TO HUNGARY: LET THEM PRIDE OR PREP FOR SHADE. ORBÁN TO EU: STAY IN YOUR LANE AND FIX YOUR OWN MESS.
Trump Escalates Criticism of Media Over Iran Strike Coverage
Trump Announces Upcoming US-Iran Meeting Amid Controversial Airstrikes
Trump Moves to Reshape Middle East Following Israel-Iran Conflict
Big Four Accounting Firms Fined in Exam Cheating Scandal
NATO Members Agree to 5% Defense Spending Target by 2035
Australia's Star Casino Secures $195 Million Rescue Package Amid Challenges
UK to Enhance Nuclear Capabilities with Acquisition of F-35A Fighter Jets
×