Dinner plate-sized surgical tool left inside woman’s body

A woman complaining of chronic pain discovered that she had a surgical tool the size of a dinner plate inside her abdomen more than a year after delivering her baby via cesarean section, health officials said.

An extra large Alexis retractor, or AWR — a device used to draw back the edges of a wound during surgery that can measure 6 inches in diameter — was left inside the mother’s body after the birth of her baby at Auckland City Hospital in 2020, according to a report by New Zealand’s Health and Disability commissioner.

“It should be noted that the retractor, a round, soft tubal instrument of transparent plastic fixed on two rings, is a large item, about the size of a dinner plate,” the newly-released report read.  “Usually, it would be removed after closing the uterine incision.”

The patient suffered agonizing pain for 18 months, until the AWR device was discovered on an abdominal CT scan and finally removed in 2021 — after multiple check-ups that failed to identify the problem.

Te Whatu Ora Te Toka Tumai Auckland, formerly known as the Auckland District Health Board, previously denied that it had failed to exercise reasonable skill and care towards the patient, pointing to “known error rates.”

On Monday, however, Health and Disability Commissioner Morag McDowell found the board 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,” McDowell wrote in her report. “It is a ‘never’ event.”

The patient had a scheduled cesarean at Auckland City Hospital because of concerns about placenta previa — a condition in which the placenta completely or partially covers the opening of the uterus.

During the delivery, a count of all surgical tools 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 was quoted in the report as saying.

One of the nurses present during the operation told the commission that she remembered opening a second AWR, which she said was “very unusual” and something she and her colleagues had never had to do before or since.

“I remember being asked by the scrub nurse to open another Alexis wound retractor … [W]e had none in the prep room, so I quickly fetched one from the sterile stock room,” the nurse said. “I opened this to the scrub nurse and left it at that.”

The nurse added that she did not include the second AWR with the tool count, “as at this time this item was not part of our count routine.”

During the next 18 months, the new mom sought medical help for her abdominal pain multiple times, including once at the Auckland City Hospital’s emergency department.

After the surgical tool was discovered in a CT scan and removed from the patient’s body, the hospital staff involved in the C-section were said to be “genuinely concerned” and “most apologetic.”

Ultimately, McDowell ruled that the health board violated the patient’s rights.

“As set out in my report, the care fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman,” the commissioner wrote. “Systems should have been in place to prevent this from occurring.”

In her report, McDowell recommended that the health board issue a written apology to the patient and, going forward, include the AWR as part of the surgical count.

Dr. Mike Shepherd, Te Whatu Ora Health New Zealand group director of operations for Te Toka Tumai Auckland, apologized 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],” Shepherd 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,” he stressed.