A woman in her 20s suffered severe pains in her abdomen after a surgical instrument the size of a dinner plate was left behind following a Caesarean, a report has found.
The woman complained to the Health and Disability Commissioner (HDC) in 2021 after the C-section in 2020 at Auckland City Hospital. The C-section was scheduled due to concerns about placenta previa and placenta accreta and occurred when the woman was at 36 weeks plus 3 days' gestation. It also wasn't her first C-section.
The surgical instrument — an extra-large Alexis wound retractor (AWR) — was "discovered incidentally" following an abdominal CT scan. It is not able to detected on an X-ray.
Health and Disability Commissioner Morag McDowell noted the woman had visited her GP several times — and the emergency department once — over her pain before the AWR was discovered to be the cause of it.
An AWR is a round, soft tubal instrument of transparent plastic fixed on two rings. It is used for holding open a surgical wound and is about the size of a dinner plate. It would usually be removed after closing the uterine incision — and before the skin is sutured.
The AWR was removed 18 months after the woman's C-section.
McDowell noted staff had no explanation for how the retractor ended up in the woman's abdominal cavity or why it was not identified before she was closed up.
The Health and Disability Commissioner said AWRs were not included in Te Whatu Ora's Count Policy at the time of the woman's C-section. The process for ensuring all surgical tools are accounted for after surgery are set out in the policy.
The Count Policy is targeted to "all staff working in the perioperative area" but a case review by the now former Auckland District Health Board (ADHB) found neither surgeon involved in the woman's C-section had read it.
McDowell noted the ADHB's case review also "identified that staff perceived the risk of an AWR being retained as low, leading to a culture of AWRs not being counted. It was also thought that the fact that the AWR was designed to be inserted into the wound with its edges on the outside of the wound contributed to this perception".
The Health and Disability Commissioner also said the Count Policy's insufficient guidance on what instruments should be included and discrepancies in who should read it had led to "systemic issues" which ADHB was responsible for at a service level.
McDowell said ADHB's care of the woman "fell significantly below the appropriate standard... and resulted in a prolonged period of distress for the woman".
"Systems should have been in place to prevent this from occurring."
She said she had "little difficulty concluding that the retention of a surgical instrument in a person's body falls well below the expected standard of care".
McDowell concluded ADHB failed to provide services with reasonable care and skill and recommended it provide a written apology to the woman and offer the opportunity to meet face-to-face, facilitated by Te Whatu Ora's Pasifika health services.
She also sought confirmation a June 2021 memo directing AWRs be included in the Count Policy going forward had been received by all Te Whatu Ora perioperative staff.
ADHB, now Te Whatu Ora Te Toka Tumai Auckland, was also referred to the Director of Proceedings to determine whether further proceedings should be taken.
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