On 21 August 2013, a woman in desperate need of a liver transplant was on the operating table and things were proving more complicated than initially hoped.
Her surgeon, Simon Bramhall, connected the new liver, but it failed to pulse, and further attempts to hook this vital organ up to the body which needed it failed until he spotted the problem.
Bramhall was an experienced surgeon who had made headlines in 2010 by saving a patient's life with a transplant using a liver which had been in a plane crash.
As for this surgery, there was a small tear on the connecting artery and with the patient's life in the balance, he appeared to finally complete the transplant.
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He then took a sample of the new liver, which would help doctors work out what went wrong quickly if the transplant didn't hold, and reached for something called an argon beam coagulator.
That's a surgical tool which passes an electrical current through a beam of argon gas and can be used to cauterise wounds, but as well as sealing up the cut in the liver, the surgeon also branded the initials 'SB' into the transplanted organ.
The burn of the beam is not deep enough to cause serious damage to the organ or stop it from working properly, and about a week later when the liver failed for reasons unconnected to the surgery, the woman ended up back on the operating table, this time under a different surgeon.
They noticed the 'SB' initials which had been burned into the surface of the liver and a picture of the mark was taken on someone's phone.
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Bramhall would later admit to marking the liver, and it also turned out he'd done it to another patient as well.
He was suspended for several months and resigned from Queen Elizabeth Hospital, Birmingham, while in 2018 he was fined £10,000 after pleading guilty to two counts of assault following one of his patients saying they felt 'violated' and their mental health had suffered significantly from the branding.
The surgeon kept working until 2020 and was struck off the medical register in 2022.
Speaking to The Guardian last year, the surgeon was asked why he branded his initials into the patient's liver and said: "I honestly don’t know.
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"Everyone in the theatre was on edge. The tension was palpable. And I guess it was a sort of lighthearted relief of that tension.
"Obviously, in hindsight, that was not appropriate and not the right thing to do. But I guess that’s how I was feeling at the time."
He said that there were two other surgeons in the room with him, and neither seemed to notice him doing it, and he doesn't remember a nurse asking him about it as she claimed that she'd challenged him on it and Bramhall had told her 'I do this'.
The surgeon claimed he definitely wasn't the only one to have used surgical tools to leave marks on patients, alleging he knows of one surgeon who 'played noughts and crosses on a liver'.
Joe Harker