“…Twitter: @DrCliffShelton; @Rose_Kearsley Case reports present the authors' perspective on a particular clinical episode, typically involving an innovation, error, complication or challenging case [1,2]. Whilst the learning that arises from case reports is situated in the circumstances of that case, there are often educational messages that can be applied in similar situations [2]. This makes case reports particularly important in alerting the peri-operative healthcare community to potential threats to patient safety and descriptions of new phenomena.…”