A device “the size of a dinner plate” was left in the abdomen of a woman in New Zealand after she gave birth via a Caesarean in an Auckland hospital.
The Alexis wound retractor – a soft tubal instrument used to hold open surgical wounds – was only removed 18 months after her delivery.
During this time, the woman endured severe pain, visiting several doctors until it was found on a CT scan.
Health regulators said the public hospital system had failed the patient.
Initially, Auckland’s health district board Te Whatu Ora Auckland had argued they had not failed to exercise reasonable care and skill.
But New Zealand’s Health and Disability Commissioner disagreed, in findings released on Monday.
“It is self-evident that the care provided fell below the appropriate standard, because the [retractor] was not identified during any routine surgical checks, resulting in it being left inside the woman’s abdomen,” Morag McDowell said.
“Staff involved have no explanation for how the retractor ended up in the abdominal cavity, or why it was not identified prior to closure,” she said.
The Alexis wound retractor is a large object made of transparent plastic fixed on two rings. Typically it is removed after the uterine incision is closed in a C-section operation and before the skin is stitched up.
It was eventually found on a CT scan but because it is a “non radio-opaque” item, it could not be detected in X-ray scans.
The Commissioner noted it was the second time in two years that a device had been left in an Auckland hospitals’ patient.
The hospital should have put in place protocols preventing the incident, which had caused “a prolonged period of distress” for the woman, Ms McDowell said.
The woman, in her 20s, consulted her GP “a number of times” in the 18 months after she gave birth in 2020 – and even went to the hospital’s emergency department on one occasion because of the pain.
The commissioner said she was “disappointed”, given that the Auckland District Health Board had already breached the code of patient rights in 2018, after it left a swab in a woman’s abdomen post-surgery.
Following that incident, the board said it would mandate that all surgical staff adhere to its “count policy”, which is supposed to ensure that staff involved in surgeries account for all items used during each procedure.
But some surgeons had not even read the policy at the time of the woman’s operation, the Commissioner said.
Te Whatu Ora Group’s director of operations for Auckland Mike Shepard apologised to the woman, in a statement reported by New Zealand media.
“We have reviewed the patient’s care and this has resulted in improvements to our systems and processes which will reduce the chance of similar incidents happening again,” he said.
“We would like to assure the public that incidents like these are extremely rare, and we remain confident in the quality of our surgical and maternity care,” he said.