A woman who suffered chronic pain for 18 months after undergoing a caesarean section was found to have a surgical instrument the size of a dinner plate inside her abdomen.
The Alexis retractor, or AWR, was left inside the New Zealand mother after her baby was delivered at Auckland city hospital in 2020.
Following initial investigations into the case, Te Whatu Ora Auckland, formerly Auckland District Health Board, claimed it had not failed to exercise reasonable skill and care towards the patient, who was in her 20s.
But on Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland in breach of the code of patient rights.
“There is substantial precedent to infer that when a foreign object is left inside a patient during an operation, the care fell below the appropriate standard,” states McDowell’s report. “It is a ‘never’ event.”
The report details that the woman underwent a scheduled C-section because of concerns about placenta previa.
“An Alexis wound retractor (AWR), a device used to draw back the edges of a wound during surgery, was left in her abdomen following her C-section. This resulted in the woman suffering chronic abdominal pain until the device was discovered incidentally on an abdominal CT scan.”
The extra large AWR, “about the size of a dinner plate” and designed to retract incisions up to 17cm in diameter, was not detectable by X-ray.
It was eventually removed from the woman’s abdomen in 2021, approximately 18 months after the initial procedure and a number of visits to her GP. On one occasion, her pain was so severe that she visited the emergency department at Auckland city hospital.
During the operation in 2020, a surgeon, a senior registrar, an instrument nurse, three circulating nurses, two anaesthetists, two anaesthetic technicians and a theatre midwife were all in theatre.
A count of all surgical instruments used in the procedure did not include the AWR, possibly “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 the commission.
The report notes that the case is “remarkably similar” to another instance in the same health authority and advises that hospital surgical count policies should be clearer.
The commissioner acknowledged that theatre staff involved in the surgery were genuinely concerned and apologetic upon hearing of the woman’s experience, but was scathing in her response to Te Whatu Ora’s claims.
“Te Whatu Ora pointed to a lack of expert evidence to support the conclusion that [the code] had been breached and referenced known error rates,” McDowell wrote.
“However, I have little difficulty concluding that the retention of a surgical instrument in a person’s body falls well below the expected standard of care – and I do not consider it necessary to have specific expert advice to assist me in reaching that conclusion.”
In a statement, Dr Mike Shepherd, Te Whatu Ora Group Director of Operations for Te Toka Tumai Auckland, apologised for the error.
“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].
“For ethical and privacy reasons we can’t comment on the details of individual patient care. However, 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. We acknowledge the recommendations made in the commissioner’s report, which we have either implemented, or are working towards implementing.”