- A surgical tool the size of a “dinner plate” was discovered in a woman’s body in New Zealand.
- The tool had been left in her abdomen for 18 months after her C-section in 2020, according to a local official.
- During the surgery, her medical team failed to account for an “extra-large” wound retractor.
A woman in her 20s, who underwent a cesarean section in Auckland, New Zealand, was shocked to discover that a surgical tool the size of a “dinner plate” had been left inside her body for 18 months.
The unidentified young mother experienced chronic pain after giving birth in 2020, as reported by Morag McDowell, New Zealand’s Health and Disability Commissioner.
Despite multiple checkups and an X-ray scan, doctors were unable to identify the source of her pain.
It was not until she was sent to the emergency department in 2021 due to severe pain that a CT scan incidentally revealed the presence of an Alexis wound retractor, a device used to expand wound openings during surgery, still inside her abdomen, according to McDowell.
The Alexis wound retractor, made of transparent plastic, was about the size of a dinner plate and is typically removed during a C-section before suturing the patient’s skin, McDowell explained.
Once discovered, the retractor was immediately removed, and the woman filed a complaint. McDowell’s review of the case revealed that Auckland City Hospital, operated by Te Whatu Ora Te Toka Tumai Auckland, previously known as Auckland District Health Board, had failed to meet medical care standards.
“It is clear that the provided care fell below the appropriate standard,” wrote McDowell, describing the incident as a “never event.”
The surgical team present during the 2020 operation included a surgeon, a senior registrar, an instrument nurse, three circulating nurses, two anesthetists, two anesthetic technicians, and a theater midwife, according to McDowell.
Mcdowell noted that a surgeon’s summary stated the use of an “extra-large” retractor due to the small size of the incision in the woman’s C-section.
Although medical teams typically count the number of instruments used before and after surgery, the counting routine at the Te Whatu Ora facility did not include Alexis wound retractors in 2020, as stated by nurses, McDowell wrote.
One nurse suggested that retractors might not be counted because they don’t go completely into the wound, but McDowell did not provide an official reason for this.
“The staff involved cannot explain how the retractor ended up in the abdominal cavity or why it was not identified before closure,” McDowell wrote.
While the Te Whatu Ora staff expressed apologies and admitted to failing to provide proper care, McDowell emphasized that this mistake was a systemic failure.
“The care in this case fell significantly below the appropriate standard, resulting in prolonged distress for the woman,” McDowell stated. “Measures should have been in place to prevent this from happening.”
McDowell instructed Te Whatu Ora to personally apologize to the woman and stated that she would refer the organization for further action to the Director of Proceedings.
In a statement to media outlets, Mike Shepherd, Te Whatu Ora Group Director of Operations for Te Toka Tumai Auckland, apologized for the error and expressed sympathy for the patient and her family.
“We sincerely apologize for what happened to the patient and acknowledge the impact it has had on her and her whānau,” Shepherd said, as reported by CNN.
Insider’s request for comment from Te Whatu Ora Te Toka Tumai Auckland went unanswered at the time of publication.
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