Doctors at a hospital in Birmingham mistakenly terminated a healthy unborn baby in a procedure instead of its sickly twin.
The unidentified mother decided to abort one of the fetuses because it was suffering from restrictive growth, which increases the chances of stillbirth and puts the healthy baby at risk.
During the procedure at Birmingham Women’s and Children’s NHS Foundation, surgeons accidentally terminated the wrong twin.
The 2019 incident emerged in a Freedom of Information Act survey of hospital blunders.
There are more than two million safety incidents reported in the NHS every year, with more than 10,000 of those resulting in severe harm and death.
Other incidents included in the survey were patients who died from falling from hospital trolleys, being given the wrong tests or medication and those being discharged too soon.
The Royal College of Obstetricians and Gynaecologists (RCOG) said selective fetal growth restriction occurs in around 10 to per cent of twin pregnancies.
An unborn baby suffering from the condition fails to get enough nourishment from the placenta and its growth is therefore stunted.
In most serious cases selective termination can improve the survival chances of the healthy fetus.
However, all such procedures can carry an increased risk of early or total pregnancy loss, the RCOG said.
A spokesperson for the group added: “Parents who undergo selective terminations of twin pregnancies face agonising decisions and report feelings of anxiety, stress and emotional trauma.
“They must be supported by their clinical team both during and after their pregnancy.”
Dr Fiona Reynolds, chief medical officer at Birmingham Women’s and Children’s NHS Trust, said: “Sadly, during a highly specialised fetal procedure in 2019 that involved operating within the womb to separate and potentially save the life of a single twin that shared a placenta, a fatal error occurred.
“A full and comprehensive investigation was carried out swiftly after this tragic case and the findings were shared with the family, along with our sincere apologies and condolences.
“The outcome of that thorough review has led to a new protocol being developed to decrease the likelihood of such an incident happening again.”