Scotland: A woman was mistakenly told her ovaries had been successfully removed when a locum surgeon mistook her for another patient, a report has revealed.
The patient, who has not been named, didn't discover she still had her reproductive organs until five months later when she returned to a consultant in pain.
She is now suing the NHS after a report found the locum may not have been "skilled enough for the complex procedure" and then gave an "unacceptable explanation" for the blunder, claiming to have "confused her with another woman."
The woman, from the Outer Hebrides in Scotland, had agreed to have a sub-total hysterectomy which removes all but the neck of the womb, after discussions with her consultant.
A locum was brought in to perform the surgery when her consultant became unavailable at short notice, the Scottish Public Services Ombudsman reports.
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The patient consented to the change.
The ombudsman report said: "Immediately after the procedure, Mrs C needed a blood transfusion because of complications, and was transferred to the High Dependency Unit.
"A few days later, the locum told her that he had done the sub-total hysterectomy, removed all of one ovary and part of the other.
"Some five months after the operation, however, Mrs C was referred back to her original consultant as she was in pain, and learned that in fact her ovaries had not been removed."
The report said she complained to the trust and the locum involved admitted he might have "confused" her with another patient when he said the ovaries were removed.
Jim Martin, Scottish Public Services Ombudsman, upheld a complaint from the patient referred to only as Mrs C in his report, concluding there were: "serious failings on the part of the locum and the board."
The report added: "When she complained to the board, they told her that the locum said that Mrs C initially did not want her ovaries removed, but changed her mind in the operating theatre.
"He said that during the operation he found that scarring from previous operations meant that it was unsafe to do so.
"He thought he might have given Mrs C wrong information because he confused her with someone else."
"The scarring means she cannot now have further surgery to complete the procedure, and she continues to be in pain."
Mr Martin said a medical advisor found nothing in her notes to show she changed her mind or the locum decided not to remove her ovaries, as would have been recorded if they happened.
He wrote: "My adviser was also concerned that the locum might not have had the skills needed for such a complex operation, and that his explanation about a mix-up was unacceptable.
"The board's response to Mrs C's concerns about the complications also seemed to demonstrate a lack of understanding of what actually happened."
"I upheld all Mrs C's complaints. I found serious failings on the part of the locum and the board both before and after the operation."
The trust is implementing recommendations in the report, including a review of locum cover, significant event and patient transfer procedures.
NHS Western Isles chief executive Gordon Jamieson said:"We would wish to publicly apologise for this patient's experience, which fell below the standard we would aim for.
"We accept the Ombudsman's recommendations and have already taken steps to action a number of these.
"We would point out that the locum was a long-term locum who worked with NHS Western Isles for a number of years as a consultant gynaecologist and was familiar with the organisation and the procedure carried out.
"We cannot comment further as it is now subject to legal proceedings."