'Wrong' woman given abortion after nurse mixed up patients



Mix-up: Ann Downer allegedly gave the drugs to a woman who had only arrived for a consultation

A woman was given a chemical abortion tablet by mistake after a nurse mixed up two patients with the same first name, a misconduct hearing has heard.

Ann Downer gave the drug to a woman who had gone into the clinic for an initial consultation.

When staff realised what had happened the distraught woman, named only as patient A, was called back to the clinic in pain and doctors subsequently advised her to undergo a surgical abortion.

Miss Downer, 44, should have administered the drug to a second woman, patient B, who was in the later stages of a chemical termination, the Nursing and Midwifery Council was told.

The first woman attended the Calthorpe Clinic in Edgbaston, Birmingham - which offers abortion, sterilisation and vasectomy - in October, 2006.

Another patient with the same name was due to have the drugs for the second stage of her medical abortion, only undertaken on women who have been pregnant for less than nine weeks.

The clinic's usual practice was to only call out first names of patients to protect their confidentiality while in the waiting room.

Once the patient was in a private room, other details such as full name, date of birth and address, were checked to make sure they were the person the nurse expected.

Miss Downer failed to carry out the identity checks and gave the drug to a patient who was only due to have an initial visit. That would have involved a consultation with a doctor, blood tests and a scan.

Patients at the first stage after the initial consultation are given a tablet of Mifepristone to swallow, which stops the growth of the foetus.

At the second stage, women are given Misoprostol to complete the abortion.

The second stage - in which Misoprostol was administered - should only follow if the patient and doctor give consent.

Nailah Mears, for the council, told the London hearing Miss Downer was in charge of treating patients at the second stage when the mixup was made.

After taking the drug, the woman commented on how quick the whole process had been and left the clinic.

She said: 'Patient A was attending the clinic for an initial consultation at 9.45am. At that stage, no part of the early medical abortion treatment is given.

'Patient B, who had the same first name, was at the clinic for her second visit at 10.45am.

'During the course of the morning, it was discovered Miss Downer had mistakenly administered the visit treatment to patient A instead of patient B.

'The registrant failed to carry out proper identity checks, and as such did not realise the treatment was being given to the wrong patient.'

Miss Mears said patient A was over the nine-week gestation period, and should not have had the early medical abortion tablets.

'Once the mistake came to light, patient A was asked to return to the clinic and was later transferred to Birmingham Women's Hospital.

'She was given an ultrasound, and that ultrasound showed that patient A was over the nine-week gestation period.

'That is very significant in determining whether the early medical abortion was appropriate. It was not appropriate in this case.'

Nurse manager Evlyn Mike told the hearing patient A was 'in pain' as she returned to the clinic.

She said: 'Apparently patient B turned up and the administration staff could not find her notes.

'They then went to Miss Downer, and at that point they realised that the wrong woman was treated with the second part of the treatment.

'They telephoned patient A and asked her to return to the clinic. She did return.

'Apparently she was in pain, and obviously very upset.'

Miss Downer, from Browns Green, Birmingham, who was not present at the hearing, had admitted mistaking one patient for another but denied not obtaining patient A's consent before doing so.

Miss Mears added: 'The council's case is that the registrant did not seek patient A's informed consent before carrying out the procedure.

'The matter for you is if there was informed and recorded consent.'

The misconduct panel ruled that Miss Downer did not obtain the woman's consent to give her the abortion drug but the nurse was allowed to carry on practising as a nurse with a three-year caution order after it was found to be an 'isolated incident'.

Panel chairman Pat Kelly said Miss Downer had expressed regret and came forward to admit her error as soon as she realised it.