HSIB report: Investigation into detection of retained vaginal swabs and tampons following childbirth (updated 15 July 2020)

Summary

Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina.

That’s the safety risk the Healthcare Safety Investigation Branch (HSIB) highlights in this report.

Content

Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete.

Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common in the ‘retained foreign objects’ category.

The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found.

Safety recommendations

HSIB made the following safety recommendation to NHS England and NHS Improvement as a result of this investigation.

• It is recommended that NHS England/Improvement carries out its intention to commission and publish an independent evaluation of its alternative design for swabs and tampons. The evaluation should also consider other solutions or technologies and include usability, cost/benefit analysis and the impact on reducing harm.

NHS England and NHS  Improvement response

The Patient Safety team at NHS England and NHS Improvement is pleased to confirm that in line with its stated intention it had already commissioned a first stage independent evaluation of a proposed new design for swabs and tampons used in healthcare maternity services.

Whilst it would not be feasible to commission an evaluation of other solutions or technologies that have not yet been well developed, further independent evaluation to compare this proposed design with other available solutions, and to evaluate potential cost benefit and impact analyses will be considered, conducted and published, should final prototypes prove possible to manufacture to the required specification and standards, and before any staged roll-out is considered.

This response was received on 15 July 2020.