Case of the month: January 2020 - wrong site endoscopy

About this case study

Each month JAG publishes a case of the month highlighting a real life clinical scenario which has impacted patient safety. Case studies are contributed by JAG leads and endoscopy services across the UK and are designed to provide an opportunity for discussion and to share learning. 

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Case synopsis

Mrs A was a 33-year-old woman referred by her GP with rectal bleeding. A routine outpatient flexible sigmoidoscopy was arranged following review in clinic.

The procedure was performed by a locum consultant endoscopist on a Sunday. The procedure was performed unsedated but Entonox was available on demand.

Following an initial digital rectal examination Mrs A was noted to have anal spasm. The endoscopist waited for the anal tone to normalise  and inserted the scope. As was his normal practice, the endoscopist froze the endoscopic image so that the patient would not see their own anus. When the image was made live, the anatomy was not correctly identified by the endoscopist or the attending nurses: the scope had been mistakenly introduced into the patient’s vagina.

Mrs A’s cervix was visualised on the endoscopy screen, which the consultant assumed to be a rectal mass and took four biopsies. There was difficulty in obtaining biopsies due to the tough texture of the tissue and the endoscopist questioned whether the scope was in the colon. He checked Mrs A’s perineum and realised that the scope was in the vagina and removed it. He placed the scope into the rectum and proceeded to perform the sigmoidoscopy which was unremarkable.

At the end of the procedure, the endoscopist asked the nursing staff to discard the cervical biopsies in the instruments sharps bin. A colleague advised that the discarded biopsies should be reclaimed and sent to pathology. The endoscopist asked the nursing staff to retrieve the biopsies from the sharps bin, which they refused to do, so he retrieved the biopsies himself after determining that the sharps bin was otherwise empty having just been replaced prior to the procedure. 

In recovery, the endoscopist gave Mrs A a full explanation of the error and apologised. He entered a report onto the incident reporting system following advice from the nursing staff. Mrs A was discharged home after recovery without any further complication.

Mrs A was later referred by the clinical governance manager to a consultant gynaecologist who concluded that the patient had not come to any harm. The trust infection control department assessed the case alongside a consultant microbiologist and determined that the risk of infection was low. The incident was reported as a ‘never event’ to NHS England and through the trust’s internal system.

JAG analysis

What are the learning points you took away from this case?
How could things have been improved?

The following patient safety incidents were identified by JAG. They have been categorised for severity (mild, moderate and severe) based on the actual or potential impact to the patient and adherence to clinical guidance, as well as by theme [2]:

 Oxygen monitoring                    
 2Distractors and time management                      
 3 Non-technical skills and training                    
 4 Documentation and reporting errors                    
 5 Technical skills and equipment                     
 6 Sedation intravenous access and monitoring                     
 7 Drug errors                    
 8 Consent                     
 9 Histology and sampling errors                    
 10 Other                    

Patient safety incident

Categorical theme


The colonoscope was misplaced into the vagina

3, 5Severe
Endoscopist did not recognise that the scope is in the vagina                                                                               
3, 5Severe

Biopsy ('Wrong site surgery') was performed


3, 9

Endoscopist retrieves discarded instruments from sharps bin                                                                               3, 9Severe
Histology samples sent to histology without usual protocols to confirm correct patient biopsies and site                                                                               
5, 9Severe
Endoscope insertion with frozen scope image                                                                               
The nursing staff did not recognise that the scope is in the vagina                                                                               
Exposure to further medical interventions (Gynaecology assessment)                                                                               


Did you identify any other patient safety incidents?



1. Avoid the practice of freezing the endoscopic image while the scope is being inserted. Instead, use direct endoscopic views as well as direct perineal examination to guide insertion. Inserting the scope over the examining digit during the rectal examination ensures the scope is inserted per rectum.                                                                                                                                                             

2. Following rectal intubation, the perineum should be inspected to ensure that the correct orifice has been used prior to further progress being made and/or biopsies being taken [1].

3. Retrieving discarded items from a sharps bin is a serious hazard and should never be undertaken.

4. Retrieving discarded histology samples can lead to incorrect samples being erroneously assigned to a patient.


1. Use the expertise of the endoscopy nurses if an unusual view is obtained

2. Consider the set-up and facilities in the procedure room, such as ensuring the procedure room is well lit prior to the insertion of the endoscope, to ensure the perineum is visualised.

3. Maintain clear communication between team members in relation to the management of biopsies.

4. It may be questionable to discard biopsies so promptly. Consider a policy to not discard samples until the end of the procedure, following a completed report.

5. Use the team brief at the start of the list to familiarise team members with visiting endoscopists. This may include dealing with areas of their practice which may be different from the expected norm . Key areas for consideration when servicesFor guidance when usinge insourcing providers can be found in the JAG insourcing guidance found at:



1. Prompt and effective communication is necessary at the time of an incident, including full duty of candour, as was done in this case [2]. There should be appropriate escalation and follow up by senior clinicians of relevant specialties with subsequent reassurance if no lasting harm has been caused by the incident.

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This case is informed by real-life events and the narrative has been adapted to enhance educational benefit. No identifiable information has been provided.

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