A large medical implement was left inside a patient's body following a cesarean section for a full 18 months, a report from NBC has revealed based on a report by Morag McDowell, the New Zealand health and disability commissioner.
The woman, in her 20s, suffered complications in a pregnancy and had the procedure in 2020. The discovery was not made until over a year later despite repeated complaints of abdominal pain.
"I acknowledge the stress that these events caused to the woman and her family. The woman experienced episodes of pain over a significant period of time following her surgery until the AWR was removed in 2021"
Morag McDowell, New Zealand health and disability commissioner
Doctors who eventually examined her discovered an extra large Alexis wound retractor, an implement used to hold open the exposed area during operations, had been left inside her body by doctors at the Auckland Hospital.
Alexis wound retractors do not show up on X-rays, making it harder for doctors to see that it was inside her.
The commissioners report found that the hospital had failed in its duty of care and the hospital issued a verbal apology, to be given in writing within three weeks.
"I acknowledge the stress that these events caused to the woman and her family. The woman experienced episodes of pain over a significant period of time following her surgery until the AWR was removed in 2021," the report said.
No oversight for retractors?
Such retractors are not included in the roll-call of medical equipment performed by the hospital at the end of each procedure.
The Auckland health authority has claimed that it previously instructed that retractors be included in the count.
Upon inquiry, the health authority stated that there was "insufficient basis to find that there was a failure to exercise reasonable care and skill in this case," but this did not impact the findings.
This is the second such incident in the Auckland area in two years. In 2021 an Alexis wound retractor was left inside a man for two weeks before being discovered.