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Surgical tool discovered inside woman, 18 months after C-section



A surgical tool the size of a dinner plate was left in a women's abdomen for 18 months following a Caesarean section at Auckland City Hospital.

On Monday, New Zealand Health and Disability Commissioner Morag McDowell found that Auckland District Health Board (now Te Whatu Ora Te Toka Tumai Auckland) breached the patient's rights after a surgical instrument was left inside her following a procedure.

Following the C-section in 2020, the woman in her 20s went to her GP several times after experiencing severe pains in her abdomen.

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After visiting the emergency department at Auckland Hospital, the instrument was discovered using an abdominal CT scan.

The instrument was an Alexis Wound Retractor (AWR), which is about the size of a dinner plate and used for holding open a surgical wound. AWR's cannot be detected on X-Ray.

"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," McDowell said.

Systems should have been in place to prevent this incident from occurring and causing a prolonged period of distress for the woman, she said.

ADHB told the commission the process for ensuring surgical tools are accounted for following surgery is set out in their 'Count Policy' – but that at the time of surgery, AWRs were not included in this process.

Theatre staff involved in the surgery provided statements to the HDC which showed genuine concern and were very apologetic upon hearing of the woman's experience, McDowell said.

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The health board's "Count Policy" provided insufficient guidance for staff to determine which instruments should be included and relied on them to use their own interpretation of what instruments were "at risk of being retained", McDowell found.

After a case in 2018 where a patient had a swab left in their abdomen, it was recommended the ADHB mandate all staff to read the "Count Policy" – McDowell said she was disappointed this recommendation was not implemented.

McDowell found ADHB was in breach of Right 4(1), which gives every consumer the right to have services provided with reasonable care and skill.

She recommended the DHB write to the woman to apologise, offer the opportunity to meet and include AWR's as part of the surgical count.

The case has also been referred to the Director of Proceedings to determine whether any further action should be taken.

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