Woman undergoes invasive procedure meant for someone else

4 June 2021

The Healthcare Safety Investigation Branch (HSIB) has produced a recent  report  which finds that improvements need to be made in outpatient clinics to avoid healthcare teams confusing patients.

A national investigation was instigated following a 39-year-old woman who went to a gynaecology clinic for a fertility assessment and instead had a colposcopy planned for another woman. Unfortunately, the lady simply misheard the name called in the clinic and as no other checks were done prior to the procedure underwent an unnecessary procedure. The error was not identified until the patient had left the clinic.

Fertility appointments often come after a long wait, and are inevitably anxiety-inducing. To have built up to that appointment only to find that the assessment wasn’t carried out must have been very difficult for the lady concerned. Dr Sean Weaver, Deputy Medical Directory at HSIB says that “Any invasive procedure carried out incorrectly has the potential to lead to a serious physical and psychological harm and erode trust in the NHS.” Apparently, the patient who was the subject of this incident was so distressed after the incident that she did not want to pursue her fertility treatment.

Healthcare teams are working incredibly hard to see many patients whose healthcare has been delayed by the pandemic. Busy clinics, combined with additional communication barriers created by the masks that are keeping us all safe means that now is the time to take the HSIB recommendations very seriously. HSIB found that there were a number of risk factors which include the verbal calling through of patients, the number of clinics operating at the same time using the same waiting space, inconsistent integration of technology which can be used to support double-checking the patient’s identity and there being no formal safety controls to manage the risk that can arise when patients have the same name.

HSIB recommends that NHS England and NHS Improvement look at the identified risks that can lead to confusion, and do what they can to address them including better use of patients NHS unique identifier number.

If have concerns about the medical care you or a loved one have received please get in touch with our team on 020 7814 1200.


If you would like any further information or advice about the topic discussed in this blog, please contact Kirsty Allen or our Medical Negligence and Personal Injury team.



Kirsty Allen has a varied caseload of medical negligence and personal injury matters. Her medical negligence work includes child cerebral palsy and adult brain injury cases, as well as fatal claims (including inquests), loss of sight cases, as well as failure to diagnose cancer and gynaecological claims.


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