2023-09-05 10:30:00
(CNN) — A surgical tool the size of a dinner plate was found inside a woman’s abdomen 18 months following her baby was born by caesarean sectionaccording to a report by the New Zealand Health and Disability Commissioner.
An Alexis retractor, or AWR, which can measure 17 centimeters in diameter, was left inside the mother’s body following the birth of her baby at Auckland City Hospital in 2020.
The AWR is a retractable cylindrical device with a translucent film used to retract the edges of a wound during surgery.
The woman suffered months of chronic pain and had multiple checkups to find out what was wrong, including X-rays that showed no trace of the device. The pain became so severe that she went to the hospital emergency department, where she had the device discovered on an abdominal CT scan and had it removed immediately in 2021.
The New Zealand Commissioner for Health and Disability, Morag McDowell, considered that Te Whatu Ora Auckland – the Auckland District Health Board – had breached the patient’s code of rights, in a report published on Monday.
The Board of Health originally alleged that a nurse, in her early 20s, who attended the woman during the caesarean section had not exercised reasonable skill and care towards the patient.
“As set forth in my report, the care provided in this case fell well below appropriate levels and caused the woman a prolonged period of distress,” McDowell stated. “Systems should have been put in place to prevent this from happening.”
The report explained that the woman was scheduled for a C-section due to concerns regarding placenta previa, a problem during pregnancy when the placenta fully or partially covers the opening of the uterus.
According to the commission’s report, during the operation, performed in 2020, the count of all surgical instruments used in the intervention did not include the AWR. This was possibly due “to the fact that the Alexis retractor does not go all the way into the wound, as half of the retractor needs to remain outside the patient and so there is no risk of being retained,” a nurse told the commission.
McDowell recommended the Auckland District Health Board apologize in writing to the woman and review its policies including wound retractors as part of the surgical count.
The case has also been referred to the director of proceedings, an official who will determine whether further action should be taken.
Dr. Mike Shepherd, Te Whatu Ora Health New Zealand Group COO of Te Toka Tumai Auckland, apologized for the error in a statement.
“On behalf of our Women’s Health service at Te Toka Tumai Auckland and Te Whatu Ora, I would like to say how sorry we are for what happened to the patient, and acknowledge the impact this will have had on her and her whānau [grupo familiar]”.
“We would like to assure the public that incidents like these are extremely rare, and we remain confident in the quality of our maternity and surgical care.”
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