Retained Surgical Body

Background

A patient in her late fifties underwent a total hip replacement. During the surgery, a sponge was placed under the acetabular cup, this was not documented in the operative note. The surgical assistant, who usually placed a clip on his gown as a reminder of the sponge’s placement, had to leave the operating theatre unexpectedly during the procedure. Although the consultant surgeon was notified of a missing sponge before wound closure, a search of the surgical field did not reveal its location. It was ultimately assumed that the sponge had been discarded in the clinical waste bin when the assistant left the operating theatre.

Incident

Five months later, at an outpatient appointment, the patient complained of thigh and hip pain. The clinician’s initial assumption was crepitus. An x-ray revealed the hip prosthesis was in a good position and the consultant reassured the patient that all was well.

However, the patient’s symptoms persisted and a repeat x-ray three months later showed a radio-opaque body in the acetabulum. The patient was readmitted for surgery. During the procedure, the sponge was removed. An abscess had formed and was duly treated with antibiotics.

Patient Complaint

The patient alleged she had not been fully informed of the findings and no apology had been offered. She subsequently initiated medicolegal proceedings against the consultant.

Learning points

1. Safe Systems: The lack of safe systems within the operating theatre contributed to the event. The use of a checklist would have assisted in ensuring all swabs were accounted for and present before wound closure.

2. Clinical Judgement and Communication: The clinical judgement of the surgeon was identified as a factor in the outcome of this case, as well as a lack of shared decision-making; poor team communication and a failure to consider a differential diagnosis which led to a delay in recognising the retained sponge.

3. Timely Management: The surgeon did not manage and investigate the patients’ symptoms in a timely manner. It is important to ensure any postoperative deterioration and/or complications are communicated, investigated and managed in a timely and appropriate manner. These details should be recorded in the patient’s medical records.

4. Professional Duty of Candour: Effective communication regarding adverse events is crucial. The consultant should have informed the patient about the adverse event, offered an apology, and adhered to the professional duty of candour.

Summary

Although much of healthcare is performed to a high standard, when things go wrong and the patient experiences an adverse outcome, it is important to investigate, explain and apologise to the patient. Please refer to the GMC’s “Openness and honesty when things go wrong: The professional duty of candour.”

An adverse event should be used as an opportunity to reflect, learn and adapt changes to a clinician’s practice and ultimately to improve care.

If you receive a complaint from a patient or a patient suffers an adverse event, please call the PMP medicolegal helpline as soon as possible, in line with the terms and conditions of your policy. The PMP medicolegal helpline team can assist customers in preparing an appropriate response.