In our case scenario, the communication might have been inadequate at the end of the procedure. The scrub practitioner either incorrectly announced that their count was correct, or had doubts about the completeness but did not express their doubt. This may be related to organisation cultural or training issues with the surgeon, midwives, scrub practitioner and HCA.
Communication problems are a recurrent theme in untoward outcomes on the labour ward and operating theatres. The WHO checklist is a valuable tool and includes swab counts and incorporates most of the crucial items of care communication relating to any surgical procedure.
The loss of a swab in the peritoneal cavity in this scenario (a ‘never event’) is the type of incident the checklist should prevent. The document will therefore feature prominently in the investigations and recommendations of the investigation report.