A woman discovered 18 months after her C-section that a surgical tool the 'size of a dinner plate' had been left in her body

• A woman in New Zealand discovered a surgery tool the size of a "dinner plate" in her body.
• It had been left in her abdomen for 18 months, after her C-section in 2020, a local official wrote.

A woman in her 20s who underwent a cesarean section in Auckland, New Zealand, discovered 18 months later that a surgical tool the "size of a dinner plate" was left in her body.

The young mother, who was not named, suffered chronic pain after the 2020 birth, wrote Morag McDowell, New Zealand's Health and Disability Commissioner, on Monday.

She went for several checkups and an X-ray scan, but doctors couldn't find the source of the pain.

When the pain became so severe that she was sent to a hospital emergency department in 2021, a CT scan "incidentally" found an Alexis wound retractor — a device used to expand a wound's opening during surgery — still in her abdomen, wrote McDowell.

Made of transparent plastic, the round and tubal instrument was "about the size of a dinner plate" and is usually removed during a C-section before the patient's skin is sutured, McDowell added.

After being discovered, it was removed immediately from the woman's body, and she filed a complaint, the commissioner wrote.

Reviewing her case, McDowell found that Auckland City Hospital, run by Te Whatu Ora Te Toka Tumai Auckland, formerly the Auckland District Health Board, had breached medical care standards.

"In my view, it is self-evident that the care provided fell below the appropriate standard," McDowell wrote, calling the incident a "never event."

Present at the 2020 operation was a surgeon, a senior registrar, an instrument nurse, three circulating nurses, two anesthetists, two anesthetic technicians, and a theater midwife, according to McDowell.

A surgeon's summary wrote that an "extra-large" retractor had been used during the woman's C-section because a large one was too small for the incision, McDowell noted.

Medical teams typically count the number of instruments used in an operation before and after surgery. But Alexis wound retractors were not part of the counting routine at the Te Whatu Ora facility in 2020, McDowell wrote, citing nurses there.

One nurse said it might be because retractors don't go into the wound completely, McDowell added. She did not specify if she found any official reason for this.

"Staff involved have no explanation for how the retractor ended up in the abdominal cavity, or why it was not identified prior to closure," she wrote.

The commissioner noted that Te Whatu Ora staff were apologetic but said they failed to provide proper care. Still, the mistake was very much a failure of the system, she added.

"As set out in my report, the care fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman," McDowell wrote. "Systems should have been in place to prevent this from occurring."

McDowell told Te Whatu Ora to apologize to the woman in person, and said she would refer the organization for further action to the Director of Proceedings.

Mike Shepherd, Te Whatu Ora Group Director of Operations for Te Toka Tumai Auckland, apologized for the error in a statement to Insider.

"On behalf of our Women's Health service at Te Toka Tumai Auckland and Te Whatu Ora, 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," Shepherd said.

September 5, 2023: This story was updated to reflect comment from Te Whatu Ora.