Recurring concern

Unreliable surgical counting controls

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First reported 17 Dec 2013•Latest report 1 Jun 2015

Definition

What this concern includes

Includes failures of dedicated surgical counting controls for swabs, syringe caps and comparable items, including establishing counts, retaining items for counting, reconciling discrepancies, documenting counts and escalating unresolved discrepancies during or at the end of an operation.

Not included

  • Excludes generic clinical documentation, staffing, training or operating-theatre governance deficiencies unless they directly impair a surgical counting control.
  • Excludes instrument, equipment or specimen tracking where the item is not part of the surgical counting process.
  • Excludes retained-item incidents or count discrepancies where the report does not identify a continuing deficiency in the surgical counting arrangements.
  • Excludes medication, implant, specimen and non-surgical inventory controls unless the assertion explicitly concerns the same surgical counting process.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2013–2015

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
Care Quality Commission1
University Hospital of South Manchester NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    David Glyn Price · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Glyn Price suffered a heart attack in early June 2011 and underwent surgery at Wythenshawe Hospital, during which a swab was inadvertently left inside his body attached to his heart; this gradually formed an abscess. Concerns included continued warfarin prescribing despite missed anticoagulation appointments, poor handwritten clinical records, failure to act on imaging showing a foreign body, and inadequate swab-count procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain an effective swab counting control during surgical procedures

    Wider context from the report

    “4. There did not seem to be in place any, or any satisfactory, swab count policy, such that none of the nurses during any of the three heart procedures, noticed that there was a discrepancy.(UHSM) ”

    Source location

    David Glyn Price · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Yorkshire (West)

    AI-generated summary

    William Alfred Andrews · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Alfred Andrews, a 77-year-old man, underwent cardiac surgery and subsequently suffered repeated circulatory arrests after a bulb syringe cap entered and remained in his left ventricle. The cap was later removed during a second operation, but his condition deteriorated and he died. Concerns included the cap's lack of visibility, inadequate awareness of its presence, and the absence of a standard procedure to check and count syringe caps at the end of surgery.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a standard procedure for checking and counting syringe caps at the end of operations

    Wider context from the report

    “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off. (2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows: It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”. No action appears to have been taken in consequence of this. (3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all. (4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation. ”

    Source location

    William Alfred Andrews · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing manufacturer safety measures, NHS surgical never-event work and revised guidance are considered sufficient to address the concerns and prevent future deaths.

    Verbatim wording from the response

    “I am pleased to note that the MHRA has made significant progress in discussions with Rocielle - the manufacturers of the syringes and have written to let you know that the manufacturers;”

    Source location

    2013-0368-Response-by-Department-of-Health
    Page 1 · response
    Published 17 December 2013

    Open published response
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Data last updated 7 September 2026