Hospital staff trained how to count swabs after they were left inside three women

An investigation launched after the incidents came to light has found they were all “avoidable” and a raft of measures has now been introduced.

Staff involved have been retrained and briefed to make sure they count swabs correctly following the three separate “never event” incidents.

And bosses insist they have “learnt lessons” and have taken the incidents “very seriously”.

Trish Armstrong-Child, director of nursing at the Trust, said: “Clearly these never events should not have happened and the Trust took these incidents very seriously.”

Bolton NHS Foundation Trust has also introduced a new ‘Swabsafe’ system to be rolled out in all theatres, to ensure accurate swab counting.

A “never event” refers to a preventable patient safety incident that should never happen.

The first two took place between July and September last year, and were discovered after the two mothers suffered health complications after the swabs became infected.

Both women gave birth naturally, and afterwards, staff used swabs — a common procedure in cases where there has been tearing of the skin.

A swab can be a cotton wool bud or a piece of gauze used to clean a wound or to apply pressure.

But in both cases, the swabs were left inside the women.

The third incident, in January this year, involved a woman who was still pregnant.

A swab was left inside her following a cervical cerclage procedure, which is when the cervix is sewn shut to minimise the risk of miscarriage.

All three women had been treated at Bolton NHS Foundation Trust’s maternity department, which was chosen to be a “supercentre” in the North West as part of Making it Better and has had £20 million invested in it over the past couple of years.

After the incidents, an investigation was launched by Bolton Clinical Commissioning Group (CCG), which found that in all three cases, the risk of harm to the patients was “low”.

But they were seen to be avoidable, and an action plan was created to prevent anything similar from happening again.

The investigation’s report said: “The CCG is acknowledges the Foundation Trust’s candid response to this series of never events and the rigorous and professional investigations that have been undertaken as a result.

“The CCG will continue to work with the FT to ensure compliance with the actions implemented and is assured that there has been appropriate.”

Ms Armstrong-Child, director of nursing at the Trust, added: “There have been several lessons learnt and I am pleased to see that the CCG recognised this. The changes that we have put in place will be monitored regularly to ensure they are fully embedded.”