A rare case of neonatal baby swap: A lesson in hospital identification protocols - report from SMGS hospital, Jammu (2025)

Abstract

This case report documents a rare and distressing incident of neonatal baby swapping that occurred at SMGS Hospital, Jammu, in 2022 and was confirmed in 2025 following DNA analysis. Two female neonates, born to mothers from different socioeconomic and geographical backgrounds one from Doda district, Jammu & Kashmir, and the other from a migrant family from Chhattisgarh were unintentionally exchanged post-delivery despite initial tagging procedures. The error remained undetected until parental suspicion led to confirmatory genetic testing three years later. This case highlights the need for strict adherence to neonatal identification protocols, the potential role of technology in preventing misidentification, and the profound psychosocial and medico-legal impact of such incidents.