The case study represents a difficult, complicated case over a weekend on a medium-sized maternity unit with a concurrent medical staffing problem. Placenta praevia is often accompanied by major haemorrhage. Haemorrhage can limit visibility and while the team is focused on controlling this, there is a higher risk of other untoward events occurring, e.g. swab misplacement. However, systems should be in place to ensure this should never occur.