New Zealand: Surgical tool ‘size of dinner plate’ left in woman’s body after operation

A woman in New Zealand who suffered chronic pain for over a year after undergoing a caesarean section was found to have a surgical instrument the size of a dinner plate left inside her abdomen. The incident has since resulted in a scathing report by the country’s health watchdog following an investigation.

The report by New Zealand’s Health and Disability Commissioner Morag McDowell was published on Monday (September 4), with this being the second case of the same surgical tool being left in a patient’s body in just two years.

‘A never event’

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An Alexis wound retractor, or AWR, was left inside the patient, a woman in her 20s, who had undergone a scheduled C-section at an Auckland city hospital in 2020.

McDowell’s report came after the initial investigation conducted by Te Whatu Ora Auckland claimed it had not failed to “exercise reasonable skill and care” towards the patient and claimed that her findings were influenced by “hindsight and outcome bias”.

However, McDowell found that the Te Whatu Ora Auckland is in breach of the code of patient rights. “There is substantial precedent to infer that when a foreign object is left inside a patient during an operation, the care fell below the appropriate standard,” she stated in the report. “It is a ‘never’ event”.

An AWR, a device used to draw back the edges of a wound during surgery, was left in her abdomen following her C-section, said the report. One of the nurses present during the operation told the commission that a count of all surgical instruments used in the procedure did not include the AWR.

But this could be because the AWR doesn’t go into the wound completely, unlike other tools, said the nurse. It was also found that a ‘large’ AWR was used during surgery but the surgeon found the tool insufficient and replaced it with an ‘extra-large’ AWR.

Image shows anAlexis wound retractor (AWR) Photo credit:The Royal College of Surgeons of England

While the surgical instrument is typically removed after the incision is closed and the skin sutured, in this case, it was forgotten.

An extra large AWR described as “about the size of a dinner plate,” is designed to retract incisions up to 17 centimetres in diameter. The tool was removed from the patient’s abdomen, in 2021, around 18 months after the initial procedure after multiple appointments with her doctor.

Reportedly, on one occasion, the pain was so severe that she visited the emergency department at the hospital. The tool was only discovered after the patient underwent an abdominal CT scan since it was invisible to an X-ray.

‘Serious deviation’

McDowell acknowledged that the theatre staff involved was genuinely concerned and apologetic after listening to what the woman had gone through, but her scathing report was directed at Te Whatu Ora’s claims.

“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.

While she accepted that Te Whatu Ora was not aware of the risk an AWR could pose when surgically retained, McDowell 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,” said McDowell calling the breach a “serious deviation” from the standard of care.

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