Recovery of surgical sponges at autopsy - Who to blame

While the counting and recounting of surgical sponges, gauze pieces and instruments before and after an operation by nursing staff and assistantsis most important feature in the prevention of accidental recovery of foreign bodies in abdomen after surgery, yet the cases are numerous where the accident occurred notwithstanding this count by one and even two nurses or assistants. The paper discusses such a case of surgery of a young adult woman who died after a caesarean section due to haemorrhage and multiple pieces of surgical sponges were recovered from the abdomen at autopsy.