A surgical instrument the size of a dinner plate was found inside a woman’s stomach 18 months after her baby was born by caesarean section, according to a report from New Zealand’s Health and Disability Commissioner.
The Alexis Retractor, or AWR, which can measure 17cm (6in) in diameter, was left inside the mother’s body after her baby was born at Auckland City Hospital in 2020.
The AWR device is a retractable cylindrical device with a transparent layer used to pull back wound edges during surgery.
The woman suffered from chronic pain for months and had several tests to find out what was wrong, including X-rays that showed no sign of the device. The pain became so severe that she visited the hospital’s emergency department and the device was discovered via a CT scan of the abdomen and promptly removed in 2021.
New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Watu Ora Auckland – the Auckland District Health Board – in breach of the Patients’ Rights Act, in a report released on Monday.
The health board initially claimed that the nurse, who was in her 20s, and who was caring for the woman during the caesarean section, had failed to exercise reasonable skill and care towards the patient.
“As set out in my report, care fell well below the appropriate level in this case and resulted in a prolonged period of distress for the woman,” McDowell said. “There should have been systems in place to prevent this from happening.”
The report explained that the woman underwent a scheduled cesarean section due to concerns about placenta previa, a problem during pregnancy when the placenta completely or partially covers the opening of the uterus.
During the operation in 2020, the committee’s report found that the count of all surgical instruments used in the operation did not include AWR. A nurse told the committee that this was probably “due to the fact that the Alexis retractor does not go completely into the wound, as half of the retractor would have to remain outside the patient and would therefore not be at risk of retention.”
McDowell recommended the Auckland District Health Board provide a written apology to the woman and review its policies by including AWRs as part of the surgical count.
The case has also been referred to the Action Manager, who will determine whether any further action should be taken.
Dr Mike Shepherd, Te Whatu Ora Health New Zealand group operations director at Te Toka Tumai Auckland, apologized for the error in a statement.
“On behalf of our Women’s Health Service at Te Toka Tomai Auckland and Te Watu Ora, I would like to say how sorry we are for what happened to the patient, and acknowledge the impact this will have on her and her family. [family group]”.
“We would like to assure the public that such incidents are extremely rare, and we remain confident in the quality of our surgical and maternity care.”
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