Swab Left in Situ During Surgery

We represented Mrs Briggs in a claim against East Surrey NHS Foundation Trust when a swab was left inside her axilla (armpit) during mastectomy surgery.

Mrs Briggs was diagnosed with breast cancer in 2017 and underwent treatment in the form of radiotherapy, chemotherapy, and an operation to remove the tumour. In 2023, she was diagnosed with bowel cancer and underwent surgery to remove part of her large intestine.

In 2024, Mrs Briggs was diagnosed with recurrent breast cancer and was scheduled for a mastectomy at Crawley Hospital which was intended to be a straightforward, day-case procedure. The surgery was completed and the swab count was reported as correct. Mrs Briggs was taken to the recovery ward and came round from the anaesthetic. Shortly afterwards, a nurse identified that a surgical swab was missing.

Mrs Briggs had an x-ray which showed that the missing swab had been left inside the site of the surgical incision. Mrs Briggs was informed that she needed to have an immediate second operation to remove the swab. The resources needed for immediate re-operation were not available at Crawley Hospital and she therefore had to be transferred to East Surrey Hospital by ambulance as an emergency. It was crucial for the operation to be performed quickly because retained surgical products cause a risk of infection.

Mrs Briggs had the surgery to remove the swab that evening. She was required to stay in hospital overnight and was sent home the following evening. Mrs Briggs developed a large seroma after the two surgeries (a pocket of fluid under the skin) which had to be drained at hospital on several occasions and which caused a lot of discomfort.

The incident affected Mrs Briggs psychologically and she experienced a period of significant anxiety for several months afterwards. She was already dealing with the emotional turmoil of facing her third cancer diagnosis and the requirement for a mastectomy, and to then have to endure a second, avoidable and emergency surgery, with a further general anaesthetic, was extremely distressing for her.

East Surrey NHS Foundation Trust produced a Patient Safety Investigation Report (PSIIR) which deemed the incident as a ‘Never Event’. Never Events are defined by NHS England as “Serious incidents that are wholly preventable”.

The Trust admitted liability and after a short period of negotiation, we settled the claim for £8,500.