Man who went to hospital for bladder check-up gets circumcised after NHS surgeons mix up his paperwork

This incident was one of eight such serious mixups and mishaps which happened at the hospital in 2017/18 alone.


                            Man who went to hospital for bladder check-up gets circumcised after NHS surgeons mix up his paperwork

A man had his penis accidentally circumcised at a hospital after the staff confused him for another patient. The unfortunate incident took place at the University Hospital of Leicester (UHL) NHS Trust in September last year and was confirmed by the hospital, though they refused to release further details of the patient by stating it was "irrelevant."

According to Leicestershire Live, the patient was scheduled to have a cystoscopy at the Leicester Royal Infirmary — a procedure where a thin camera is used to look inside the bladder — but his notes were mixed up with that of another man who was due to have a circumcision. 

The mishap happened at the Leicester Royal Infirmary in September 2018 (Source: Google Maps)
The mishap happened at the Leicester Royal Infirmary in September 2018 (Source: Google Maps)

The error came to light in a document produced by the Leicester City Clinical Commissioning (CCG) compiling what are called "never events" at the hospital. Never events are defined as serious, largely preventable safety events that should not occur if the preventative measures are implemented correctly and include operating on the wrong patient, wrong site surgery, or even foreign objects left in a person's body after an operation.

The circumcision case was one of eight different "never events" which occurred at UHL in 2018 alone. These included a swab left in a child following an adenoidectomy — a surgical procedure where tissue is removed from behind the nasal passages; wrong site radiology which resulted in the patient consenting to a wrong surgery; wrong patient surgery because of a mixup of notes involving two patients with similar names; and a wrong implant/prosthesis where the wrong side hip nail was implanted in a patient.

In its damning report, the CCG said the incidents were because of the hospital's inability to learn from previous never events. "Failure to demonstrate learning from never events has been a concern for Leicester, Leicestershire and Rutland commissioners and partners for some time," they wrote. "The CCG has an important role in continuing to support UHL to achieve their quality and safety ambitions and intends to do this modeling the comprehensive and collaborative approach described within the CQC report."

The circumcision was one of eight 'never events' which took place at the hospital in 2017/18 (Source: Pixabay)
The circumcision was one of eight 'never events' which took place at the hospital in 2017/18 (Source: Pixabay)

Leicestershire Live reported that when questioned about the report stating UHL had not learned from past mistakes, a spokesman refused to elaborate further. However, the trust did release a generic statement where they insisted they were committed to improving.

"We remain deeply and genuinely sorry to those patients involved, and of course we have personally apologized to each one," said Moira Durbridge, Director of Safety and Risk at Leicester’s Hospitals. "Local and national learning (from NHS Improvement and the Healthcare Safety Investigation Branch) from Never Events suggests that there can be a number of system issues and human factors that can lead to human error. We are committed to learning and improving and have enshrined this work into our clinical priorities within our Quality Strategy for 2019/20."