AUCKLAND, New Zealand — New Zealand’s Health and Disability Commissioner reported on Monday, September 4, 2023, that a surgical tool, an Alexis retractor or AWR, had been left inside a woman’s abdomen for 18 months after she gave birth via cesarean section at Auckland City Hospital in 2020.
The AWR, a retractable cylindrical device measuring 17 centimeters (6 inches) in diameter, is used to hold back the edges of a surgical wound.
The woman, whose name has not been released, experienced chronic abdominal pain for months after the surgery.
Despite numerous medical consultations and X-rays, the foreign object remained undetected until she was finally admitted to the emergency department for a CT scan in 2021.
New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland — the Auckland District Health Board — to be in violation of the code of patient rights.
The board had initially pointed the finger at a nurse in her 20s, alleging she had not exercised “reasonable skill and care” during the procedure.
“As set out in my report, the care fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman,” McDowell said. “Systems should have been in place to prevent this from occurring.”
The woman had undergone a scheduled C-section because of a medical condition called placenta previa, where the placenta covers the opening of the uterus.
According to the report, a count of all surgical instruments used during the operation omitted the AWR.
“A nurse explained to the commission that the Alexis Retractor doesn’t go into the wound completely as half of the retractor needs to remain outside the patient. Therefore, it was not considered at risk of being retained,” the report stated.
In addition to requiring a written apology to the woman, McDowell recommended that the health board revise its policies to include AWRs in surgical instrument counts.
The case has also been forwarded to the director of proceedings, who will assess whether further action is warranted.
Dr. Mike Shepherd, Te Whatu Ora Health New Zealand group director of operations for Te Toka Tumai Auckland, issued a public apology.
“On behalf of our Women’s Health service at Te Toka Tumai Auckland and Te Whatu Ora, I would like to say how sorry we are for what happened to the patient, and acknowledge the impact this will have had on her and her whānau [family group].”
“We would like to assure the public that incidents like these are sporadic, and we remain confident in the quality of our surgical and maternity care,” Shepherd added.
The case has ignited public debate over surgical safety protocols and raised questions about the efficacy of current systems designed to prevent such medical errors.
As health care systems worldwide grapple with the complexities of medical treatments, this incident is a stark reminder of the human consequences that can arise when those systems fail.
