Nzherald.co.nz reported that doctors at Auckland City Hospital in 2020 left an ‘extra-large’ Alexis wound retractor, or AWR — used to draw back the edges of incision during C-section — inside the abdomen of the woman, who was in her 20s. AWR can measure up to 17 centimetres in diameter.
Typically, the tool would be removed as soon as the uterine incision was closed and the skin sutured. In this case, it was forgotten.
After suffering months of chronic pain and several checkups, including X-rays that showed no sign of the device, it was discovered on an abdominal CT scan and removed immediately in 2021, the report said.
New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland — the Auckland District Health Board — in breach of the code of patient rights, in a report released on Monday.
“There was not sufficient basis to find that there was a failure to exercise reasonable skill and care,” claiming her opinion was influenced by hindsight and outcome bias, Te Whatu Ora Auckland told McDowell.
“Te Whatu Ora pointed to a lack of expert evidence to support the conclusion that [the code] had been breached and referenced known error rates,” McDowell wrote.
In a statement, Te Whatu Ora Group director of operations for Auckland Mike Shepard apologised to the woman.
“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 whanau (extended family). For ethical and privacy reasons we can’t comment on the details of individual patient care.
“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. We acknowledge the recommendations made in the Commissioner’s report, which we have either implemented, or are working towards implementing.
“We would like to assure the public that incidents like these are extremely rare, and we remain confident in the quality of our surgical and maternity care.”
–Ajit Weekly News
rvt/dan
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