Man accidentally circumcised in hospital mix-up

Incident one of eight ‘never events’ to take place at University Hospitals of Leicester NHS Trust in 2018

Chiara Giordano
Tuesday 26 March 2019 12:34
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Man accidentally circumcised in hospital mix-up

A man was accidentally circumcised after a hospital mistakenly carried out the wrong procedure.

The patient was supposed to have a cystoscopy – a procedure which examines inside the bladder using a thin camera.

But surgeons instead removed his foreskin after mixing up his medical notes with another patient who was meant to have a circumcision in September 2018.

The error was one of eight “never events” which took place at University Hospitals of Leicester NHS Trust last year, a Leicester City Clinical Commissioning Group report revealed.

The trust said it was deeply sorry and that it was committed to learning and improving.

It also did not provide an answer when asked how the circumcision incident was allowed to happen.

Eight ‘never events’ to happen at hospitals run by University Hospitals of Leicester NHS Trust in 2018

- A man was circumcised when he had actually consented to cystoscopy – a procedure which examines inside the bladder using a thin camera.

- A swab was left in a child who had had an adenoidectomy – a surgical procedure to remove tissue from behind the nasal passages.

- Two patients with similar name notes were mixed up, resulting in one of them having the wrong operation.

- A patient consented to the wrong surgery after a mistake with the consent form process.

- Two cases of unintentional connection of patient to requiring oxygen to an air flowmeter.

- Surgeons incorrectly marked a patient for an angiogram – an X-ray test which involves a special dye being passed through a catheter to show any narrowed areas or blockages in the arteries. 

- A patient had a hip nail implanted in the wrong side.

However, the report said one of the key contributing factors was failure to learn from a previous never event.

Moira Durbridge, director of safety and risk at Leicester’s Hospitals, said: “We remain deeply and genuinely sorry to those patients involved, and of course we have personally apologised to each one.

“We are committed to learning and improving and have enshrined this work into our clinical priorities within our quality strategy for 2019/20.”

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