A UK man who went to hospital for a bladder examination was circumcised instead after a surgeon mixed him up with another patient, an NHS report has revealed.
The patient had been scheduled to have a cystoscope - a bladder inspection with a camera.
However, surgeons instead removed his foreskin after his notes were mixed up with a patient due to have a circumcision.
The error was one of eight "never events" which took place at the University Hospital of Leicester NHS Trusts in 2018.
Never events are serious mistakes that could have been prevented and are considered so shocking they should never occur.
Leicester City Clinical Commissioning Group (LCCCG) also revealed a swab was left inside a child after nasal surgery.
In April, another patient was given surgery intended for another man with a similar name.
The report stated: "Failure to demonstrate learning from never events has been a concern for Leicester, Leicestershire and Rutland commissioners and partners for some time.
"The CCG has an important role in continuing to support UHL to achieve their quality and safety ambitions and intends to do this modelling the comprehensive and collaborative approach described within the CQC report.
"This will be achieved through continuing to strengthen our relationships and aligning our improvement approach around a common set of clinical priorities."
The hospital's director of safety, Moira Durbridge, said: "We remain deeply and genuinely sorry to those patients involved, and of course we have personally apologised to each one.
"We are committed to learning and improving and have enshrined this work into our clinical priorities within our quality strategy for 2019/20."
NEVER EVENTS AT THE HOSPITAL IN 2018
January: Patient wrongly connected to air flowmeter instead of oxygen.
March: Swab left inside child who had adenoidectomy.
April: Patient wrongly connected to air flowmeter instead of oxygen.
April: Medics mix-up notes of men with similar names meaning patient has wrong operation.
May: Patient had wrong surgery after blunder with consent form process.
June: Surgeons incorrectly mark a patient for an angiogram.
September: Male patient mistakenly circumcised when he was supposed to have a cystoscopy.
November: Patient has a hip nail implanted in the wrong side.