3. Mrs T complains a GP at the Practice used a contaminated swab when they carried out a high vaginal swab test on 30 December 2022.
4. Mrs T feels violated and traumatised as she spent months fearing she may have been infected with a blood-borne disease such as HIV or hepatitis. This fear subsequently negatively impacted her relationship with her husband.
5. Mrs T would like financial compensation in recognition of her traumatic experience.
6. Mrs T had a high vaginal swab at the Practice at 10.50am on 30 December 2022. At 4.08pm she received a phone call from the Practice stating the doctor had utilised a swab that had already been used on another patient. Mrs T attended a hospital for blood tests to identify if she had been infected with any blood borne diseases but was informed these diseases can take up to three months to show up in a blood test.
7. On 30 March 2023 Mrs T undertook blood tests to determine if she had been infected with any blood borne disease as a result of the used swab. These tests showed Mrs T had not been infected.
10. On 30 December a doctor at the Practice conducted a pelvic exam on Mrs T. The records state ‘Took swab – but realised late that the sample was not done properly as swab seems to have been used’. The doctor made a further entry explaining they had asked the nurse to pass them a swab, which they then used. They had since realised it had already been used as a genital swab by a different patient.
11. The Practice has acknowledged its staff should have used a sterile swab when conducting a high vaginal swab on Mrs T.
12. As this did not happen, this amounts to a failing. Patient Safety is a key element of the NHS Constitution. The NHS patient safety strategy also explains the importance of patient safety and the steps the NHS is taking to improve this. We are not reassured the Practice’s actions, by using an already used swab on Mrs T, were in line with this.
13. We next considered what the impact of the failing was on Mrs T. The use of an already used swab put Mrs T at the risk of being infected with blood borne diseases such as hepatitis and HIV. The nature of these diseases mean they cannot be detected in a newly infected person for up to three months. This means Mrs T spent three months not knowing if she had been infected with a potentially life-changing disease.
14. The blood test results Mrs T received on 30 March 2022, three months after the swab, showed she had not been infected. This means there was no medical impact of the Practice’s failing. However, Mrs T has clearly explained the significant emotional impact she experienced.
15. There were three months between Mrs T finding out about the used swab and learning she had not been infected with a life-altering blood borne disease. Mrs T has stated she spent this time living in fear she had been infected with HIV or hepatitis and that that fear negatively impacted her relationship with her husband.
16. We considered what the Practice has already done to put right the impact of the provisional failings on Mrs T and whether there is more that it needs to do.
17. The Practice provided Mrs T with an apology from the doctor who performed the high vaginal swab. The doctor said, ‘I would like to apologise again for the incident that happened on 30 December 2022, when I used a contaminated swab by mistake during my consultation with you’. This apology also stated that the doctor would be undertaking a course on infection prevention and control, would ensure all swabs they take in future are labelled as soon after the consultation as possible, and they would ensure they always open a new packet of swabs when a nurse is assisting them.
18. The Practice also apologised for the level of service Mrs T received and informed her the doctor who carried out her swab would no longer be training at the Practice.
19. We are reassured these service improvements will help to prevent the same thing from happening again. We are satisfied they are also in line with our ‘Principles for Remedy’ which say public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.
20. However, there is more the Practice needs to do to acknowledge and put right the impact of the failing on Mrs T. Our Principles for Remedy also say where poor service has led to injustice, public bodies should try to offer a remedy that returns someone to the position they would have been in otherwise. If that is not possible, the remedy should compensate them properly.
21. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we recommend the Practice pays Mrs T £500 in recognition of the emotional distress she suffered as a result of the failing.
1. During our investigation, we identified failings in a GP practice in the Kirklees area (the Practice) care and treatment of Mrs T. Specifically, that the Practice utilised a used swab when conducting a high vaginal examination on Mrs T. We have seen no evidence there was a medical impact on Mrs T. However, we did consider there was an impact of severe and prolonged emotional distress and anxiety. Therefore, we uphold Mrs Ts complaint.
2. We recommend the Practice pays Mrs T £500. This recommendation reflects the serious and prolonged emotional impact on her.
22. We recommend that: • Within four weeks of the date of this final report, the Practice pays Mrs T £500 in recognition of the three months of significant distress she experienced as a result of it utilising an already used swab.