Surgical equipment and materials left in patients.

This article seeks to examine the issue of lost equipment and materials left in patients and the assumptions that registered theatre practitioners make. The assumptions are highlighted using a tragic case study that relates to a young lady who died and what the subsequent post mortem revealed: five pieces of gauze in her abdominal cavity which were proved to be five surgical swabs. The problem of retained swabs and other surgical equipment is far greater than many would believe.