Doctors in New Zealand discovered a “dinner-plate sized” surgical device inside the abdomen of a woman who had given birth via cesarean section (C-section) 18 months before, according to authorities.
The woman, who has not been named, suffered months of chronic pain following her baby’s birth at Auckland City Hospital in 2020, according to a Sept. 4 press release from New Zealand’s Health and Disability Commissioner.
Despite multiple visits to the doctor and X-rays to determine the cause of her pain, the source remained a mystery until her condition worsened, sending the new mother to the emergency room, a report from the Health And Disability Commissioner stated.
After performing an abdominal CT scan, doctors finally discovered that an Alexis retractor, or AWR, had been left inside her body following her c-section months before, according to the report. The AWR, described as a dinner-plate sized soft tubal instrument designed to hold open a surgical wound, was removed from the woman’s abdomen 18 months after her c-section, the release stated.
Plate-sized surgical tool left in woman’s abdomen for 18 months https://t.co/zx6BspQ9Ps
— BBC News (World) (@BBCWorld) September 5, 2023
“[T]he care fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman,” Health and Disability Commissioner Morag McDowell determined after the investigation into Auckland District Health Board (ADHB) – now Te Whatu Ora Te Toka Tumai Auckland, the release stated. “Systems should have been in place to prevent this from occurring,” McDowell continued.
The investigation found that at the time of the surgery, AWRs were not included as part of the surgical count. “[A]s far as I am aware, in our department no one ever recorded the Alexis Retractor on the count board and/or included in the count. This may have been due to the fact that the Alexis Retractor doesn’t go into the wound completely as half of the retractor needs to remain outside the patient and so it would not be at risk of being retained,” a nurse told investigators, according to the report.
McDowell determined that ADHB “had an operational responsibility to ensure that appropriate systems were in place to encourage a culture of safety and to support clinicians to carry out their roles safely and effectively.”(RELATED: Country Gives Priority To Certain Races For Surgeries In Bid To Reduce ‘Inequities’)
“For the retention of an AWR in the woman’s abdomen during surgery, and the above failures in its system, I consider that ADHB failed to provide services with reasonable care and skill,” McDowell concluded in the report.
McDowell recommended ADHB offer the woman a written apology for the oversight and revise its policies by including AWRs as part of the surgical count.
“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 that this will have had on her and her whānau [family group],” Dr Mike Shepherd, Te Whatu Ora Health New Zealand group director of operations for Te Toka Tumai Auckland, said in a statement.
“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,” Shepherd continued.