Miss Y, 37 years old, was known to have bilateral ovarian endometrial cysts, which were treated surgically by Mr D, a consultant gynaecologist. Repeat scans after surgery showed recurrence of the cysts, which were subsequently managed with dydrogesterone.

She subsequently presented as an emergency, complaining of severe dysmenorrhoea for three days. Bilateral ovarian cysts were again confirmed on a trans-vaginal ultrasound scan and a decision was made for her to undergo further surgery.

Mr D performed a laparotomy and found recurrent bilateral ovarian cysts stuck down in the pouch of Douglas and adherent to the back of the broad ligament. Both fallopian tubes were dilated but otherwise normal. Mr D recorded that the right ovary was freed and chocolate coloured material aspirated.

The left ovary was drained in situ, but no attempt was made to free it. Before the operation, Mr D inserted a small pack into the posterior fornix in an attempt to keep the uterus and ovaries elevated. Miss Y had never been sexually active.

Miss Y made an uneventful recovery and was discharged from hospital on day four. Three weeks later she was referred back to the gynaecology department with increasing pain and urinary incontinence. Clinical examination demonstrated left iliac fossa tenderness but an ultrasound scan was negative.

A diagnosis of dysmenorrhoea, secondary to endometriosis, was made as the patient had begun menstruating two days earlier. The patient declined admission to hospital as she was anxious to go home. Mefenamic acid was prescribed and she was reviewed by Mr D two weeks later.

At this stage she complained of a foul smelling vaginal discharge although her pain and urinary symptoms had settled. A high vaginal swab was taken and the patient was given continuous progesterone for three months and doxycycline for ten days. At a further review two weeks later the patient was well with no evidence of discharge, but an offensive odour was detected.

Betadine vaginal pessaries were prescribed and Miss Y was asked to reattend in three weeks. Upon reattendance, it was found that the foul smelling discharge had resumed. Further swabs revealed the presence of faecal organisms and the betadine pessaries were continued.

The patient’s problems persisted. Eight months after the original operation she was reviewed again by Mr D who performed a speculum examination. This revealed the pack in the posterior fornix, which was removed, and the vagina washed with betadine. In addition, antibiotics were prescribed. The patient subsequently made a full recovery.

The patient initiated proceedings against Mr D, citing negligence in failing to remove the pack during the operation. A further complaint was also made that Mr D failed to suspect or locate the pack after surgery by not taking reasonable steps to heed or investigate her complaints. Responsibility for not removing the pack and failing to diagnose its presence for several months was accepted and the case was settled for a moderate sum.

Learning points

Such incidents as described in this case report continue to occur after operative procedures with variable degrees of subsequent harm. Each organisation and individual surgical team need to implement safety checks and take responsibility for ensuring that all surgical instruments and packs or swabs used in an operation are counted in and counted out. The World Health Organisation Surgical Safety Checklist has been widely implemented and has specific elements to help reduce the risk of such events. See www.who.int for more information.