By Kenneth Williams-
An Army veteran has been left a double amputee after doctors allegedly removed the wrong leg. A 74-year-old Army veteran went into an Ohio hospital expecting to lose one leg. She emerged from surgery having lost the other.
Sharon Jacks is now suing Selby General Hospital in Marietta, Ohio, and members of the medical and surgical teams, alleging that doctors amputated her healthy left leg instead of the cancer-affected right leg they were supposed to remove.
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The operation took place on 19 September 2025. According to the lawsuit, Jacks had agreed to a below-the-knee amputation of her right leg as part of treatment for squamous cell carcinoma. Instead, the surgical team allegedly removed her left leg. Four months later, the right leg was also amputated, leaving Jacks without either lower leg.
But it is one detail in the allegations that makes the case particularly disturbing: the wrong leg was allegedly removed despite the correct leg having been marked and despite two surgical “time-outs” being documented before the procedure.
Jacks’ lawyer, Brad Layne, says medical records show that the correct leg had initially been marked. According to the lawsuit, the mark was still visible on the right leg after the left leg had been amputated.
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The complaint alleges that the surgical team failed to properly identify and verify the correct operative extremity despite several opportunities to stop the procedure.
The hospital has acknowledged that something went seriously wrong. A spokesperson described the incident as an “avoidable event” and said the expected operating-room procedures were not followed.
The hospital said the staff involved were held accountable and were no longer in their positions, and that surgical staff were retrained following the incident.
Jacks and her husband have named nine defendants. The lawsuit alleges gross negligence, battery and reckless conduct and seeks damages for physical injury, permanent disability, pain and suffering, emotional distress, medical expenses and loss of enjoyment of life. Those allegations have not been finally determined by a court
However, the consequences are already permanent. Her lawyer says the error has transformed ordinary tasks such as dressing, cooking and moving around the home. She now has to transfer herself between her wheelchair and other surfaces simply to get to bed or use the bathroom, according to reports on the case.
The “never event” that still happens
Wrong-site surgery is classified as a “never event” in patient-safety systems—a term used for particularly serious, preventable incidents that should not occur when established safeguards are properly followed. The classification does not mean such incidents literally never happen.
In the United States, the Joint Commission’s latest sentinel-event data show that 127 wrong-surgery events were reported in 2024, up from 112 in 2023 and 89 in 2022. Of the 127 wrong-surgery events recorded in 2024, 86—68%—were classified as wrong-site procedures. Of those wrong-site cases, 48 involved the wrong side of the body.
The numbers need to be treated carefully. The Joint Commission’s figures are reports of sentinel events rather than a census of every operation performed in America, so they cannot be used to calculate the overall probability of a wrong-site operation.
Nevertheless, they demonstrate that the problem has not disappeared despite decades of safety initiatives. A major academic study published in JAMA Surgery, examining more than 2.8 million operations, identified 25 non-spinal wrong-site operations, producing an estimated incidence of approximately one in 113,000 operations.
Researchers concluded that wrong-site surgery was extremely rare but that existing verification procedures could not have prevented every case examined. That finding is significant because it challenges the comforting assumption that adding another tick-box to a surgical checklist automatically eliminates human error.
Britain has its own warning signs
The United Kingdom has experienced the same problem. NHS England’s provisional figures for April 2025 to March 2026 recorded 403 reported Never Events, including 166 classified as wrong-site surgery. Within that category were 40 wrong-side/site procedures, 38 wrong-site blocks and 22 cases involving removal or biopsy of the wrong skin lesion.
The figures have fluctuated over the years but wrong-site surgery has remained a recurring category. NHS England recorded 178 wrong-site surgery Never Events in 2022/23, while the equivalent figure for 2021/22 was 179. The history illustrates why surgical safety systems have increasingly focused on layers of verification rather than relying on a single person’s memory or assumption.
A UK study examining surgical-list errors in an NHS board found 86 wrong-site or wrong-side list errors in 29,480 cases, equivalent to 0.29%. Nearly three-quarters of those errors—72.1%—were wrong-side errors.
Importantly, these were list errors rather than completed wrong-site operations, demonstrating how many potential disasters may be intercepted before the patient reaches the operating table.
There have also been documented British cases in which the safety barriers themselves have failed. NHS material examining human factors describes, for example, a case where a child underwent surgery on the wrong wrist after a junior doctor noticed the apparent error but the concern was not acted upon; the mistake was discovered only after the incision had been made.
Another NHS case involved a patient scheduled for a left shoulder procedure who received a right-sided nerve block despite the surgical site having been appropriately marked. The investigation identified factors including documentation errors, reliance on memory and the marking being obscured by the patient’s gown.
The lesson running through these cases is uncomfortable: the danger is not simply that somebody makes a mistake. It is that several people, systems or safeguards can fail to stop the mistake before irreversible harm occurs.
There is a particularly striking American precedent. In 1995, a Florida surgeon mistakenly amputated the left foot of a diabetic man when the right foot was intended.
The case resulted in litigation and a settlement, and the surgeon was subsequently involved in another amputation-related error involving a woman’s toe. The Florida medical authorities later suspended his licence.
The case prompted the hospital to introduce additional procedures intended to prevent similar errors. The historical case became a vivid example of why wrong-site surgery is regarded as qualitatively different from many other medical mistakes: once the incision has been made and the wrong limb removed, there is no meaningful way to undo the error.
That is why modern surgical systems use measures such as site marking, patient identification, consent verification and the surgical “time-out”—a deliberate pause intended to make the entire team confirm the patient’s identity, procedure and operative site before surgery begins.
The Joint Commission says one of the commonly identified causes of wrong-site surgery is failure to follow established safety protocols. Its current patient-safety standards continue to emphasise verification of the correct patient, procedure and site.
The question raised by Jacks’ case
The most important question raised by the Ohio lawsuit may therefore not be simply “How did the surgeon cut off the wrong leg?” How did the system fail to stop the wrong operation when the safeguards were supposedly already in place?
If the allegations are ultimately established, the case would represent a particularly stark example of what patient-safety specialists have spent decades trying to prevent: an error occurring not because there was no safety procedure, but because the procedures failed to interrupt the chain of events leading to irreversible harm.
The alleged presence of a correct surgical mark and two documented time-outs makes that question even more difficult.
It also explains why wrong-site surgery continues to occupy a disproportionate place in patient-safety discussions despite its rarity. The issue is not merely how often these events occur. It is that the harm can be permanent, immediate and impossible to reverse.
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