CNN
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A surgical instrument the size of a dinner plate was found inside a woman’s stomach 18 months after her baby was born by caesarean section, according to a report from the New Zealand Commissioner for Health and Disability.
The Alexis retractor, or AWR, which can be 17 centimeters (6 inches) in diameter, was left inside the mother’s body after the birth of her baby at Auckland City Hospital in 2020.
The AWR is a cylindrical, retractable device with a translucent coating that is used to pull wound edges back during surgery.
The woman suffered from chronic pain for several months and underwent several tests to find out what was wrong, including x-rays that showed no sign of the device. The pain was so severe that she visited the hospital’s emergency department and the device was discovered via a CT scan of her abdomen and promptly removed in 2021.
New Zealand’s Health and Disability Commissioner, Morag McDowell, found that Te Watu Ora Auckland – the Auckland Region Health Board – breached the Patients’ Rights Act, in a report released on Monday.
The Board of Health initially claimed that the nurse, who was in her twenties, who was attending to the woman during the caesarean section, had failed to exercise skill and reasonable care towards the patient.
“As indicated in my report, care fell far short of the appropriate standard in this case and led to a prolonged period of distress for the woman,” McDowell said. “There should have been systems in place to prevent this from happening.”
The report said the woman underwent a scheduled caesarean section due to concerns about placenta previa, a problem during pregnancy when the placenta completely or partially covers the uterine opening.
During the operation in 2020, the committee’s report found that the number of all surgical instruments used in the operation did not include AWR. A nurse told the panel that this might be “due to the fact that the Alexis retractor does not go all the way into the wound, as half of the retractor would have to remain outside the patient and would therefore not be in danger of being retained”.
McDowell recommended that the Oakland Region Board of Health make a written apology to the woman and revise its policies by including AWRs as part of the surgical count.
The case has also been referred to the Actions Manager, who will determine if any further action should be taken.
Dr Mike Shepherd, director of group operations for Te Whatu Ora Health New Zealand in Te Toka Tumai Auckland, apologized for the error in a statement.
“On behalf of our Women’s Health Service at Te Toka Tomai Auckland and Te Watu Ora, I would like to say how sorry we are about what happened to the patient, and acknowledge the impact this will have on her and her family. [family group]”.
“We would like to assure the public that such incidents are extremely rare, and we remain confident in the quality of our surgical and maternity care.”
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