A woman has found her surgeon had left a device the size of a dinner plate in her abdomen after giving birth at a New Zealand hospital by caesarean in what was a stunning medical mishap.
The discovery of the Alexis wound retractor – a soft tube instrument used to hold open surgical wounds – came just 18 months after the first operation at Auckland City Hospital.
The woman suffered severe pain during that agonizing year and a half and sought help from multiple doctors until a CT scan finally revealed the shocking truth, sparking outrage and calls for responsibility.
First, Auckland Health Authority Te Whatu Ora Auckland argued vehemently that they exercised reasonable care and skill during the procedure.
But health officials have condemned the public hospital system, claiming it has completely failed the patient.
In a scathing assessment, New Zealand Health and Disability Commissioner Morag McDowell stated: “It is evident that the care provided was below the appropriate standard because.” [the device] was not identified during routine surgical examinations, resulting in it remaining in the woman’s abdomen.
“The personnel involved have no explanation as to how the retractor entered the abdominal cavity or why it was not identified prior to closure.”
The discovery of the Alexis wound retractor – a soft tube instrument used to hold open surgical wounds – came just 18 months after the first operation at Auckland City Hospital
Auckland City Hospital
Mike Shepard, Te Whatu Ora Group’s operations manager for Auckland, later apologized to the woman after regulators railed against the health board.
“We reviewed the patient’s care and this has led to improvements in our systems and processes that reduce the likelihood of similar incidents occurring again,” he said.
“We want to reassure the public that incidents like this are extremely rare and we remain confident in the quality of our surgical and obstetric care.”
The Alexis Retractor is a large clear plastic device suspended between two plate-sized rings. It is used to keep surgical wounds open during surgery and is typically removed during a caesarean section after the uterine section has been closed.
The woman underwent multiple X-rays, but the item was not discovered because it is “non-radiopaque” – meaning it could only be identified by the more sophisticated, 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 patient safety concerns.
The commissioner expressed her disappointment, pointing out that the Auckland District Health Board had broken the Code of Patients’ Rights back in 2018 after a similar incident involving a swab left after an operation left in a woman’s stomach.
According to McDowell, the hospital was therefore expected to have strict protocols in place to prevent such mishaps from happening again, and after that incident the board had promised to enforce its “counting policy” to ensure all operating room staff were carefully checked over accounts for every item used during the interventions.
But McDowell claimed some surgeons at Auckland City Hospital hadn’t even read the guidelines at the time of the woman’s caesarean.
Analysis of the numbers shows that UK surgeons have fished out a record number of “foreign objects” from inside patients over the past year.
Errors related to items accidentally left in the body during surgical and medical care resulted in a record 291 “consultant episodes completed” in 2021/22.
Items can include swabs, gauze, or even surgical equipment, including drills. Two decades earlier, in 2001/02, there were 156 of these episodes.
The lowest number in the last 20 years was in 2003/04, when 138 episodes were recorded by doctors.
Errors related to a “foreign body accidentally left in the body during surgical and medical care” resulted in a record 291 “completed consultant episodes” in 2021/22. This can include swabs, gauze, or even surgical equipment, including drills. Two decades earlier, in 2001/02, there were 156 of these episodes
Data from NHS England shows that from April 2021 to March 2022, 98 cases of foreign bodies – including scalpels and drills – were left in patients after procedures in England. The graph shows: The most common items left with patients during the year
Last year, the average age of patients with an internal foreign body was 57 years.
However, patients from infants to those over 90 years of age are affected.
Swabs and gauze used during an operation or procedure are among the most common items left inside a patient. However, on rare occasions, surgical tools such as scalpels and drills have been found.
Strict procedures are in place in hospitals to prevent such errors, including checklists and repeated counting of surgical instruments.
Leaving an item inside 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, executive director of the Patients Association, said: “Incidents are never called that because they are serious incidents that are totally preventable because the hospital or clinic has systems in place to prevent them.”
“When they do occur, the severe physical and psychological effects they cause can follow a patient for the rest of their life and that should not happen to anyone seeking treatment from the NHS.”
“While we are fully aware of the crisis the NHS is facing, events should never occur when the preventive measures are implemented.”
A previous analysis published in May 2022 found that around 407 never-recorded events were recorded in the NHS in England from April 2021 to March 2022.
Vaginal swabs were left in patients 32 times and surgical swabs 21 times.
Other items left inside the patients included part of a wire cutter, part of a scalpel blade and the bolt of a pair of surgical forceps.
On three separate occasions during the year, part of a drill remained inside a patient.