Surgeon leaves tool size of dinner plate in woman’s abdomen after C-section, removed 18 months later

A woman was left with a large surgical tool in her abdomen for 18 months, the health watchdog has found. Stock photo / 123rf

A woman who suffered severe pain after giving birth via caesarean sought medical attention several times over 18 months before doctors eventually realised an instrument the size of a dinner plate had been left inside her abdomen.

The incident is the second case of the same surgical tool being left in a patient’s body in just two years - resulting in a scathing report from the health watchdog.

But despite the mistake, Te Whatu Ora claimed the watchdog’s findings were influenced by “hindsight and outcome bias” and said it was unfair to conclude the mistake showed a failure of reasonable skill and care.

Today Health and Disability Commissioner Morag McDowell disagreed, finding Te Whatu Ora Auckland in breach of the code of patient rights.

According to the findings, the woman in her 20s had undergone a scheduled C-section at Auckland City Hospital in 2020.

A ‘large’ Alexis wound retractor, or AWR, was used to draw back the edges of her incision during surgery, but the surgeon found the tool insufficient. She replaced it with an ‘extra-large’ AWR.

Typically, the tool would be removed as soon as the uterine incision was closed and the skin sutured. In this case, it was forgotten.

At the time of the surgery, McDowell found AWRs were not typically included within the surgical count (the tally of all items used in surgery).

“As far as I am aware, in our department no one ever recorded the Alexis Retractor on the count board and/or included in the count,” one nurse told her. The nurse said this was likely because the AWR doesn’t go into the wound completely, unlike other tools.

The surgery occurred at Auckland City Hospital in 2020. Photo / Jason Oxenham

The tool was only discovered after the patient underwent an abdominal CT scan. The material of the tool meant it was non-radio-opaque and was invisible to X-ray.

Te Whatu Ora Auckland undertook its own review after the incident, which resulted in a directive that AWRs are to now be included in surgical counts. The Health and Disability Commissioner conducted its own investigation.

Upon providing its provisional findings, Te Whatu Ora Auckland told McDowell “there was not sufficient basis to find that there was a failure to exercise reasonable skill and care,” claiming her opinion was influenced by hindsight and outcome bias.

“Te Whatu Ora pointed to a lack of expert evidence to support the conclusion that [the code] had been breached and referenced known error rates,” McDowell wrote.

“Te Whatu Ora submitted that the risk of an AWR being retained was not known by its staff, and that without the benefit of hindsight there is no sufficient basis to find that there was a failure to exercise reasonable care and skill in this case.”

McDowell accepted that Te Whatu Ora was not aware of the risk an AWR could be surgically retained, but had “little difficulty concluding that the retention of a surgical instrument in a person’s body falls well below the expected standard of care.

“I do not consider it necessary to have specific expert advice to assist me in reaching that conclusion,” she wrote, saying the breach was a “serious deviation from the [expected] standard of care.”

McDowell further criticised the surgical count policy at the time, which allowed for staff to make their own interpretation as to what should have been counted. She also noted that the surgeons involved in this surgery hadn’t even read the surgical count policy.

This was a particularly disappointing development, she said, referring to another Health and Disability Commission investigation in 2018 which found Auckland DHB left a swab in a patient’s abdomen.

A recommendation from that investigation was that all surgical staff were to read the surgical count policy, which was never implemented.

She also referred to a case that had almost identical facts from 2019, in which a cancer patient was also left with an AWR in his abdomen. The former Waitemata DHB was forced to apologise.

She recommended Te Whatu Ora Auckland provide evidence that a directive to include AWRs in the surgical count has been relayed to all staff, provide the HDC with an update on learning and assessment modules for surgeons, implement the findings from its own review, and apologise to the woman.

In a statement, Te Whatu Ora Group director of operations for Auckland Mike Shepard apologised to the woman.

“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. For ethical and privacy reasons we can’t comment on the details of individual patient care.

“However, we have reviewed the patient’s care and this has resulted in improvements to our systems and processes which will reduce the chance of similar incidents happening again. We acknowledge the recommendations made in the Commissioner’s report, which we have either implemented, or are working towards implementing.

“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.”

McDowell referred the case to the director of proceedings to determine if any further action should be taken.

Ethan Griffiths covers crime and justice stories nationwide for Open Justice. He joined NZME in 2020, previously working as a regional reporter in Whanganui and South Taranaki.