A woman had to take an HIV test after a doctor performed an intimate examination on her with a swab that had already been used on someone else’s genitals.
The Health Ombudsman for England, which investigated the incident, is urging GPs to be vigilant to ensure infection prevention and control processes are followed to make sure this does not happen again. The 40-year-old woman visited her GP in Batley in December 2022 for a vaginal examination for an existing health condition. After the examination was carried out, the mother-of-one was told the swab had previously been used on someone else.
The woman was told she was at risk of contracting blood-borne diseases such as HIV and hepatitis. She had to wait three months before being tested for HIV and was told the results were negative.
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She complained about her experience at the doctor’s surgery, but after being outraged by his response, she took the case to the Parliamentary and Health Service Ombudsman (PHSO).
The woman, who lives near Leeds and did not want to reveal her identity, said: “When I found out the swab had already been used and I would have to be tested for HIV and hepatitis, I was very upset and scared. I was in shock and worried about what this could mean for my health.
“It was a huge mistake and I still can’t understand how it happened. I accept that humans make mistakes, but the way the practice dealt with it was appalling. They were apathetic and didn’t understand what I had been through.
“The mistake was serious enough at first, but the subsequent treatment was even worse. That is why I reported it to the Ombudsman, as no one acknowledged the anguish I suffered for three months.”
The practice, which has not been identified by the Health Ombudsman, has since apologised to the woman and taken steps to ensure this does not happen again.
However, the PHSO found that the practice had not done enough to acknowledge its mistake and put it right, the Ombudsman said. He recommended that the practice pay the woman £500 in recognition of the suffering caused, and the practice complied.
Ombudsman Rebecca Hilsenrath said: “We all know that mistakes happen. There is always the potential for human error in any profession. Fortunately, in this case this serious error had no medical repercussions.
“The focus of our research was the impact on the patient. For three months, she had to live with the uncertainty of whether she might be suffering from a serious illness, with all the implications that this entailed for her own life and that of her son.
“The firm failed to address this issue and it needed to be corrected. The firm has now acknowledged its mistakes and has taken steps to ensure the same mistake does not happen again. This demonstrates the power of complaints to resolve issues like this.”
