After enduring 18 months of chronic pain following a caesarean section, a woman in New Zealand was shocked to discover a surgical instrument the size of a dinner plate lodged within her abdomen. This medical mishap unfolded at Auckland City Hospital in 2020, where the Alexis retractor (AWR) inadvertently remained inside her body following the birth of her child.
Initially, Te Whatu Ora Auckland, formerly known as Auckland District Health Board, asserted that it had upheld the requisite standards of care and skill in treating the patient, a woman in her twenties. However, New Zealand’s Health and Disability Commissioner, Morag McDowell, delivered a different verdict on Monday, finding Te Whatu Ora Auckland in violation of patient rights.
McDowell’s report emphasized the established precedent that leaving a foreign object inside a patient during surgery constitutes a grave lapse in care, deeming it a “never” event. The woman had undergone a scheduled C-section due to concerns about placenta previa, and the AWR was unintentionally left behind during the procedure. This oversight caused her persistent abdominal pain until the device was incidentally detected via an abdominal CT scan.
The AWR, an unusually large instrument roughly the size of a dinner plate, designed to retract incisions up to 17cm in diameter, eluded detection by X-ray. Ultimately, it was extracted from the woman’s abdomen in 2021, nearly a year and a half after the initial surgery, following numerous visits to her general practitioner and even an emergency department visit due to excruciating pain.
During the 2020 operation, a multitude of medical professionals, including surgeons, nurses, anesthetists, and technicians, were present in the operating theater. A count of surgical instruments employed in the procedure failed to account for the AWR. According to a nurse, this omission may have occurred because the Alexis Retractor does not need to be fully inserted into the wound, with half of it remaining outside the patient, potentially leading to its oversight.
The report underscored the striking similarity of this case to another within the same healthcare authority and recommended clearer hospital surgical count policies.
While the surgical staff involved expressed genuine concern and regret upon learning of the woman’s ordeal, McDowell strongly refuted Te Whatu Ora’s claims. She criticized the health authority for citing a lack of expert evidence to support the breach of the code, asserting that retaining a surgical instrument within a patient’s body unquestionably falls below the expected standard of care.
In response, Dr. Mike Shepherd, Te Whatu Ora Group Director of Operations for Te Toka Tumai Auckland, issued an apology and pledged to implement improvements to prevent such incidents in the future, acknowledging the recommendations made in the commissioner’s report.
