This is an account of a significant event that occurred in clinical practice. The incident highlights issues that can arise from a breakdown of verbal and non-verbal communication between members of staff. It also demonstrates how professional conduct and effective team working can overcome such breakdowns to elicit a positive outcome. Using Johns (2009) model of structured reflection (MSR), this article reflects on the student operating department practitioner's (ST/ODP) role as anaesthetic support, exploring the impact on the care received by the patient, whilst examining the ethico-legal (governing body and legislation) considerations involved. Furthermore, the ST/ODP proposes to identify environmental and intra-operative factors that are potentially damaging to the patient's well being, through understanding the principles of negligence, emphasising clinical governance, vicarious liability and risk management issues.