According to a report from New Zealand’s Health and Disability Commissioner, a surgical implement roughly the size of a dinner plate was discovered inside a woman’s abdomen a year and a half after she underwent a cesarean section to deliver her baby.
The object in question was an Alexis retractor, also known as an AWR, which can have a diameter of up to 17 centimeters (approximately 6 inches). Shockingly, this retractable cylindrical device with a translucent film, typically used to pull back the edges of a surgical wound during an operation, was inadvertently left inside the mother’s body following her baby’s delivery at Auckland City Hospital in 2020.
Following the surgery, the woman endured several months of chronic pain and underwent multiple medical examinations to determine the source of her suffering. Even X-rays failed to reveal any trace of the device. As her pain intensified, she eventually sought help at the hospital’s emergency department, where an abdominal CT scan uncovered the AWR, leading to its immediate removal in 2021.
Morag McDowell, New Zealand’s Health and Disability Commissioner, released a report on Monday that found Te Whatu Ora Auckland, also known as the Auckland District Health Board, to be in violation of patient rights. Initially, the health board attributed the mishap to a nurse in her twenties, alleging a lack of reasonable skill and care in her treatment of the patient.
In McDowell’s words, “As detailed in my report, the level of care provided in this case fell significantly below the required standard, resulting in prolonged suffering for the woman. Measures should have been in place to prevent such an incident.”
The report clarified that the woman had undergone a scheduled C-section due to concerns related to placenta previa, a pregnancy complication where the placenta either fully or partially covers the uterus’s opening. During the 2020 procedure, the AWR was not counted among the surgical instruments used, possibly because the Alexis Retractor doesn’t enter the wound entirely, with half of it remaining outside the patient, making it less susceptible to retention, as explained by a nurse during the commission’s investigation.
McDowell recommended that the Auckland District Health Board issue a written apology to the woman and revise its policies to include AWRs in surgical instrument counts. The case has also been referred to the director of proceedings, an official responsible for determining whether further actions should be taken.
In a statement, Dr. Mike Shepherd, Te Whatu Ora Health New Zealand’s group director of operations for Te Toka Tumai Auckland, expressed remorse for the error, stating, “On behalf of our Women’s Health service at Te Toka Tumai Auckland and Te Whatu Ora, I would like to convey our heartfelt apologies for the ordeal the patient went through and acknowledge the impact it had on her and her whānau [family group].”
