A surgical tool — the size of a dinner plate (an Alexis retractor)— was removed from a woman’s abdomen as the medical professionals who performed a cessarian operation on her forgot to remove it after the procedure.
The incident occurred in Auckland, New Zealand in 2020. The object was removed from the woman’s body in 2021.
On Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland – the Auckland District Health Board – in breach of the code of patient rights.
Initially, the health board had claimed that a nurse — in her 20s — failed to exercise reasonable skill and care towards the patient during the procedure.
However, McDowell observed: “As set out in my report, the care fell significantly below the appropriate standard in this case, resulting in a prolonged period of distress for the woman. Systems should have been in place to prevent this from occurring.”
The report found that the medical professionals did not count the AWR among the surgical instruments used. This was possible “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.
McDowell has asked the Auckland District Health Board to apologise to the woman and revise its policies by including AWRs 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 director of operations for 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 that this will have had on her and her whānau [family group].”
“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.”