A woman had to be tested for HIV after a doctor performed an intimate exam with a swab that had already been used on another person’s genitals.
England’s Health Ombudsman, who investigated the incident, is urging GPs to be vigilant about ensuring infection prevention and control processes are followed to make sure this does not happen again.
The 40-year-old mother-of-one visited her GP in Batley in December 2022 for a vaginal examination for an existing health condition. After the examination was carried out, she was told that the swab had previously been used on another person.
The woman was then told she was at risk of being infected by blood-borne diseases including HIV and hepatitis. She had to wait three months before she could be tested for HIV and learn that the results were negative.
She complained about the experience to the doctor’s surgery, but after being dissatisfied with their response brought the case to the Parliamentary and Health Service Ombudsman (PHSO).
The woman, who lives near Leeds, said:
“When I found out the swab had already been used and I would need to have tests for HIV and hepatitis, I was extremely upset and scared. I was shocked and worried about what this might mean for my health.
“It was a grave error, and I still can’t fathom how it happened. I accept that humans make mistakes, but the way the practice dealt with it was appalling. They were apathetic and not understanding of what I had been through.
“The mistake was bad enough in the first place, but the aftercare was worse. That is why I escalated it to the Ombudsman as there was no acknowledgement of the distress I experienced for three months.”
The practice had already apologised to the woman and put steps in place to make sure this doesn’t happen again.
However, PHSO found that the practice had not done enough to acknowledge its failing and put it right. It recommended that the practice pay the woman £500 in recognition of the distress caused. It has complied.
Ombudsman Rebecca Hilsenrath said:
“We all know that mistakes happen. There is always the possibility for human error in any profession. Fortunately, in this instance this serious mistake had no medical repercussions.
“The focus of our investigation was the impact on the patient. For three months, she had to live with the uncertainty of whether she could be suffering from a serious disease, with all the implications that entailed for her own life and that of her child. This was not addressed by the practice and needed to be put right. The practice has now acknowledged its failings and taken steps to make sure the same mistake doesn’t happen again. This shows the power of complaining in bringing resolution to issues like this.”
Read the case summary.