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When we talk about Never Events in healthcare, the word “never” is not a suggestion. It should be a promise. A line in the sand. Yet for too many women, that promise is being broken.

Retained swabs in maternity care following childbirth remain the most common Never Event, despite being entirely preventable. What should be a joyous and life-changing moment can instead lead to pain, infection, trauma , and, in the most tragic cases, loss of life.

Cases That Should Never Happen

The devastating incident at Southend Hospital, where swabs were left inside three patients, and where one woman tragically died,  shows just how high the stakes are.

1. As Echo News reported, the hospital acknowledged serious failings, sparking legal claims and internal investigations. Costly both financially and reputationally.

2. In another case outlined in the Legal analysis from RWK Goodman underscored that these incidents are not isolated or historic anomalies. Instead, they remain worryingly common across maternity care settings in the UK.

The Hidden Toll of Retained Swabs in Maternity Care on Women and Staff

The physical consequences of a retained swab are obvious: pain, infection, fertility issues, even death. But there is also a hidden toll:

• Women who lose trust in the very system meant to protect them.
• Families left devastated by preventable harm.
• Healthcare staff carrying the burden of second victim syndrome,  where the psychological impact of causing harm undermines their confidence, mental health, and willingness to speak up.

Each incident reverberates far beyond the maternity ward, shaking confidence in healthcare systems and cultures.

Systemic Reform: How to Prevent Retained Swabs

Checklists, manual counts, and staff vigilance are not enough. Time and again, investigations reveal how errors creep ing, during shift changes, under extreme pressure, or when teams are overstretched.

To make safety non-negotiable, systemic reform must include:

• Technology-enabled verification to back up manual counting.
• Safety-first cultures where staff can speak up without fear of blame.
• Learning health systems that translate investigations into real prevention.

Never Should Mean Never

Every retained swab is one too many. The fact that they remain the most common Never Event in maternity care should alarm us all.

Women deserve safer maternity care. Families deserve reassurance that avoidable harm will not strike again. And healthcare staff deserve systems that protect them, as much as their patients.

Because when we say Never Event, we must mean it.

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