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BMJ. 1998 August 29; 317(7158): 558.
PMCID: PMC1174670
Records mix up causes unnecessary sterilisation
Xavier Bosch
 
A mix up of medical records has resulted in a healthy Spanish pregnant woman having her ovaries and uterus removed.

In April 1997 Rafaela Martínez Ruiz, aged 39, was examined by a gynaecologist at the university public hospital Reina Sofía in Córdoba, Andalucia. After initial examination she was told that she had slight endometritis. But three months later she was called urgently and told that she had endometrial cancer and needed surgery. In August 1997 she underwent elective total hysterectomy and double oophorectomy.

When the results of the pathology tests were available the head of the gynaecology unit told the woman's husband that she did not have cancer, that there had been a computer error, and that the uterus had contained a fetus that was few weeks old. Her records had been mistaken for those of a 71 year old woman with the same name who did have cancer of the uterus. Mrs Ruiz has been receiving psychiatric treatment for depression ever since.

Unable to reach agreement with the hospital and the Andalucian health service for compensation, Rafaela Ruiz has sued them, accusing them of serious imprudence and causing an abortion. It has been suggested that she will demand the highest damages ever reported in the history of Spanish public health. Her lawyers have criticised the negligence and irresponsibility of the doctors, who seemed unaware of the healthy uterus and the existence of a fetus. The public health authority has admitted that "a human error was the cause of the lamentable confusion."

On 17 August this year the hospital director resigned and the Andalucian health service opened disciplinary proceedings against the heads of the gynaecology and pathology units at the hospital.