A woman who was left with chronic pain after having a baby via c-section was horrified to discover she had a surgical tool the size of a dinner plate left inside her abdomen more than a year later.
The unnamed mum, from New Zealand, was left in agonising pain after giving birth in 2020 but despite having multiple check ups the object went unnoticed for 18 months when it was picked up on during an abdominal CT scan.
The object in question was an extra large Alexis wound retractor, or AWR — a device used to draw back the edges of a wound during surgery.
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A newly published report from New Zealand’s health and disability commissioner stated: "The Case Review found that it was this second AWR (size XL) that was retained.
"It should be noted that the retractor, a round, soft tubal instrument of transparent plastic fixed on two rings, is a large item, about the size of a dinner plate.
“Usually, it would be removed after closing the uterine incision (and before the skin is sutured)."
Te Whatu Ora Te Toka Tumai Auckland, formerly known as the Auckland District Health Board, had previously argued that it had not failed to exercise reasonable care and skill.
However, New Zealand's Health and Disability Commissioner Morag McDowell disagreed, saying: "It is self-evident that the care provided fell below the appropriate standard, because the [retractor] was not identified during any routine surgical checks, resulting in it being left inside the woman's abdomen.
"Staff involved have no explanation for how the retractor ended up in the abdominal cavity, or why it was not identified prior to closure.”
She added: “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.
“It is a ‘never’ event.”
In a statement Dr. Mike Shepherd, Te Whatu Ora Health New Zealand group director of operations for Te Toka Tumai Auckland, apologised for the incident.
“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 that this will have had on her and her whānau,” he said.
“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.”
Claire Reid