OAN’s Brooke Mallory
12:07 PM – Tuesday, September 5, 2023
According to an official report, a woman had excruciating discomfort when, unbeknownst to her, a “dinner plate-sized” medical gadget had been left inside her stomach for 18 months following childbirth via a caesarean (C) section.
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The treatment was performed on the unnamed 20-year-old patient in 2020 as a result of issues with her pregnancy and “elevated maternal body mass,” according to the report, which was made public on Monday by Morag McDowell, the New Zealand Health and Disability Commissioner.
Months after the delivery of her child, the woman complained of excruciating ongoing stomach pain, and physicians soon determined that an Alexis wound retractor, a spherical, soft tubular device used to bring back the margins of a wound during surgery, had been inadvertently left inside of her body.
The patient repeatedly complained of continuous stomach pain to her doctor, and on one occasion she even visited Auckland Hospital’s emergency room in the country’s largest metropolis.
The forgotten tool was dismissed for so long in part because it was “non-radio opaque,” making it invisible to x-ray scans.
According to McDowell, the Auckland Health Authority failed in its responsibility to take care of the woman.
“I acknowledge the stress that these events caused to the woman and her family. The woman experienced episodes of pain over a significant period of time following her surgery until the AWR was removed in 2021,” McDowell said in the report. “I accept her concerns regarding the impact this had on her health and wellbeing and that of her family.”
According to the report, a large wound retractor was utilized during the C-section procedure, but the surgeon thought it was too small and requested an extra-large model.
When another CT scan was performed more than a year later, it was this second, much larger device that had been left within the patient.
The complaint further stated that the retractors were not accounted for when medical equipment was tallied in the hospital department.
The Auckland health authority, also known as Te Whatu Ora Te Toka Tumai Auckland, doubled down by stating that it had correctly performed its duties by informing personnel that the retractors should be included in the count.
“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 [family]. For ethical and privacy reasons we can’t comment on the details of individual patient care,” said Mike Shepard, Te Whatu Ora’s group director of operations for Aukland. “However, we have reviewed the patient’s care and this has resulted in improvements to our systems and processes which will reduce the chance of similar incidents happening again.”
The director of procedures for the commissioner has now been handed the case, and they have the authority to file disciplinary actions that might eventually lead to the termination of individual employees who were involved in the medical error.
However, this is not a unique incidence.
In 2021, a similar incident occurred in the Auckland suburb of Waitemat when an Alexis wound retractor was introduced into a patient’s stomach during emergency surgery to repair a perforated colon. It was accidentally left in place and caused the patient great discomfort and nausea until it was finally discovered and removed more than two weeks later.
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