ABSTRACT
A patient suffering from a perforated duodenal ulcer was admitted to hospital. The combined effects of his having food in his stomach and poor tolerance of the anaesthetic administered made the emergency operation difficult. At the conclusion of the operation, the surgeon asked the theatre sister (who had been ‘flagging’ and counting all of the swabs) whether all the swabs had been removed. She replied that they had, but she was in error. The patient died.
