A MUM feared she had HIV after a doctor performed a vaginal exam with a swab that had already been used on another patient.
Following the "grave error", the 40-year-old was then forced to wait an agonising three months for her test results.
These came back negative. But investigators have urged GPs to be vigilant about proper infection prevention measures to make sure this never happens again.
Rebecca Hilsenrath, England’s health ombudsman, said: "We all know that mistakes happen.
"There is always the possibility for human error in any profession.
"Fortunately in this instance, this serious mistake had no medical repercussions."
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The mum-of-one visited her GP in Batley, West Yorkshire, in December 2022 for a vaginal examination for an existing health condition.
After it was carried out, she was told the swab had previously been used on another person's genitals and she was at risk of being infected by blood-borne diseases, including HIV and hepatitis.
Because these can take months to show up, the patient, who lives near Leeds, had to wait 90 days before she could receive accurate results.
She complained about the experience to her doctor's surgery, but was dissatisfied with their response so brought the case to the Parliamentary and Health Service Ombudsman (PHSO).
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"When I found out the swab had already been used and I would need to have tests for HIV and hepatitis, I was extremely upset and scared," she said.
"I was shocked and worried about what this might mean for my health.
"It was a grave error, and I still can’t fathom how it happened.
"I accept that humans make mistakes, but the way the practice dealt with it was appalling.
"They were apathetic and not understanding of what I had been through.
"The mistake was bad enough in the first place, but the aftercare was worse.
"That is why I escalated it to the Ombudsman as there was no acknowledgement of the distress I experienced for three months."
'SERIOUS DISEASE'
The practice had already apologised to the woman and said it had put steps in place to make sure the error is never repeated.
However, the PHSO found that the practice had not done enough to acknowledge its failing.
It recommended that the surgery pay the woman £500 in recognition of the distress caused. It complied.
Ms Hilsenrath said: "The focus of our investigation was the impact on the patient.
"For three months, she had to live with the uncertainty of whether she could be suffering from a serious disease, with all the implications that entailed for her own life and that of her child.
"This was not addressed by the practice and needed to be put right.
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"The practice has now acknowledged its failings and taken steps to make sure the same mistake doesn’t happen again.
"This shows the power of complaining in bringing resolution to issues like this."
Are you at risk of HIV?
HIV is a virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease.
An estimated 106,890 people are living with the condition in the UK.
In most cases, it spreads through unprotected sexual contact with an infected person.
Most people will experience flu-like symptoms two to six weeks after being infected.
This tends to include a sore throat, fever and a rash all over the body, which lasts one to two weeks.
After this, HIV may not cause any symptoms at all, but the virus continues to damage your immune system.
Some people go on to experience weight loss, night sweats, thrush in the mouth, an increase in herpes or cold sore outbreaks, swollen glands in the groin, neck or armpit, long-lasting diarrhoea, and tiredness.
While there is no cure for HIV, there are very effective treatments that enable most people with the virus to live long and healthy lives.
Medication now reduces the amount of the virus in the body to the point of being undetectable, meaning it cannot be transmitted.
The only way to find out if you have HIV is to have a test. This involves giving a sample of your blood or saliva.
The most effective ways to prevent or reduce the risk of infection include using a condom for sex, post-exposure prophylaxis, pre-exposure prophylaxis, treatment for HIV to reduce the viral load to be undetectable, and never sharing needles or other injecting equipment, including syringes, spoons or swabs.
Source: NHS