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.

Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in several procedures 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 never event in the ‘retained foreign objects’ category.

Reference event

This 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 tampon was found.

Investigation summary

Our investigation looked at the detection and design of vaginal swabs and tampons.

The investigation found that:

  • Whilst current methods like ‘count practices’ (using whiteboards to count and track the whereabouts of equipment in theatres) have had some success, they are not a robust barrier in reducing risk.
  • The lack of visibility of swabs and tampons also contributes to the likelihood that they will be accidentally left in. NHS England/Improvement is exploring potential solutions including a redesign to swabs and tampons and will publish its full evaluation in due course.

Download and read the full report.

Safety recommendations

We’ve made a safety recommendation to NHS England/Improvement as a result of this investigation.

We expect them to respond to their safety recommendation within 90 days of the publication of the investigation report. Their response will be shared here when it’s available.

NHS England/Improvement

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.

Find out more by reading our report launch news story.