A woman has discovered that her surgeon left a plate-sized device in her abdomen after she gave birth via caesarean section at a New Zealand hospital following an overwhelming medical accident.
The discovery of the Alexis Wound Retractor – a soft tubal instrument used to hold open surgical wounds – was made just 18 months after the initial operation at Auckland City Hospital.
The woman endured severe pain throughout this agonizing year and a half, seeking help from multiple doctors until a CT scan finally revealed the shocking truth, sparking outrage and calls for accountability.
Initially Te Whatu Ora Auckland, Auckland’s health district board, vehemently argued that they had exercised reasonable care and skill during the proceedings.
But health care regulators have condemned the public hospital system, claiming it has utterly failed the patient.
In a scathing review, New Zealand Commissioner for Health and Disability Morag McDowell stated: ‘It goes without saying that the care provided was below the appropriate standard because (the device) was not identified during routine surgical checks, which resulted in it being left inside. woman’s belly.
“Involved employees have no explanation for how the retractor entered the abdominal cavity and why it was not identified before closure.”
The discovery of the Alexis Wound Retractor – a soft tubal instrument used to hold open surgical wounds – was made just 18 months after the initial operation at Auckland City Hospital.
Auckland City Hospital
Mike Shepard, director of operations for the Te Whatu Ora Group for Auckland, later apologized to the woman after regulators railed against the health board.
“We have reviewed patient care and this has resulted in improvements to our systems and processes that reduce the likelihood of similar incidents occurring again,” he said.
“We want to assure the public that incidents like this are extremely rare, and we remain confident in the quality of our surgical and maternity care.”
The Alexis Wound Retractor is a large transparent plastic device suspended between two plate-sized rings. It is used to keep surgical wounds open during surgery, and during cesarean delivery, it is usually removed after the uterine incision has closed.
The woman underwent several X-ray scans, but the item was not discovered because it is ‘not radio-opaque’ – meaning it could only be identified by the more advanced, three-dimensional CT scan.
This shocking incident marks the second time in just two years that a foreign object has been left in a patient at an Auckland hospital, raising serious concerns for patient safety.
The commissioner expressed disappointment, pointing out that the Auckland District Health Board had previously breached the patient rights code in 2018 following a similar incident where a smear was left in a woman’s abdomen after surgery.
Therefore, the hospital was expected to have strict protocols in place to prevent such accidents from happening again, McDowell said, and after that incident, the board had pledged to enforce its “counting policy” to ensure that all surgical staff are meticulously accountable for each item used. during procedures.
But McDowell claimed some surgeons at Auckland City Hospital hadn’t even read the policy at the time of the woman’s C-section.
It’s because analysis of figures shows British surgeons fished a record number of ‘foreign objects’ out of patients last year.
Blunders involving objects accidentally left in the body during surgical and medical care led to a record 291 ‘completed consultant episodes’ in 2021/2022.
Items can include cotton swabs, gauze, or even surgical tools, including drills. Twenty years earlier, in 2001/2002, there were 156 of these episodes.
The lowest number in the past twenty years was in 2003/2004, when doctors registered 138 episodes.
Blunders involving a “foreign object accidentally left in the body during surgical and medical care” led to a record 291 “completed consultant deliveries” in 2021/2022. These can be cotton swabs, gauze pads, or even surgical tools, including drills. Twenty years earlier, in 2001/2002, there were 156 of these episodes
Data from the NHS England shows that from April 2021 to March 2022 in England, there have been 98 cases of a foreign object – including scalpels and drills – being left on patients after procedures. The graph shows: the most common objects left with patients during the year
Last year, the average age of patients with a foreign body in them was 57 years.
But patients ranging from infants to people over the age of 90 have been affected.
Cotton swabs and gauze pads used during a surgery or procedure are among the most common items left with a patient, but surgical instruments such as scalpels and drills have been found on rare occasions.
There are strict procedures in hospitals to prevent such blunders, including checklists and repeated counting of surgical instruments.
Leaving an object in a patient after surgery is classified by the NHS as a ‘never event’ – meaning the incident is so serious it should never have happened.
Rachel Power, CEO of the Patient Association, said: ‘Events are never called that because they are serious incidents that are completely preventable because the hospital or clinic has systems in place to prevent them from happening.
‘If they do occur, the serious physical and psychological consequences they cause can remain with the patient for the rest of their lives, and that should never happen to anyone seeking treatment on the NHS.
“While we fully appreciate the crisis facing the NHS, events should never simply not happen if preventive measures are implemented.”
A previous analysis, published in May 2022, found that between April 2021 and March 2022, some 407 never-events were recorded on the NHS in England.
Patients were left with vaginal swabs 32 times and surgical swabs 21 times.
Some of the other items left with patients included part of a pair of wire cutters, part of a scalpel blade, and the bolt of surgical tweezers.
On three separate occasions during the year, part of a drill was left in a patient.