AUCKLAND, New Zealand: A dinner plate-sized surgical device was left in a woman’s abdomen in New Zealand after she gave birth via a Caesarean in an Auckland hospital.
A woman in New Zealand had a surgical tool, described as “the size of a dinner plate,” left inside her abdomen following a Caesarean section at an Auckland hospital.
The Alexis wound retractor, a soft tubal instrument used to keep surgical wounds open, was discovered and removed 18 months after her delivery. During that time, she endured severe pain and consulted multiple doctors before a CT scan revealed the object, as reported by BBC News.
Health regulators determined that the public hospital system had failed the patient. District health authorities, Te Whatu Ora Auckland, initially argued that they had not breached the standard of reasonable care and skill. However, New Zealand’s Health and Disability Commissioner disagreed with the findings.
The Commissioner, Morag McDowell, stated, “It is self-evident that the care provided fell below the appropriate standard because the [retractor] was not identified during any routine surgical checks, resulting in it being left inside the woman’s abdomen.” She further noted that the surgical team at Auckland City Hospital had replaced the initial Alexis wound retractor with a larger one, and this second retractor was left inside the woman.
The Alexis wound retractor is a sizable transparent plastic device fixed on two rings, typically removed after closing the uterine incision in a C-section but before stitching up the skin. Due to being “non-radio-opaque,” it couldn’t be detected in X-ray scans and was ultimately found via a CT scan.
The Commissioner pointed out that this incident marked the second time in two years that a device had been left in a patient at an Auckland hospital, emphasizing that the hospital should have had effective protocols.
The woman, in her 20s, sought medical help multiple times during the 18 months following her 2020 childbirth due to pain and discomfort. The report did not disclose her current health status, although the Commissioner did not mention any lasting harm. The case is now under legal review to determine if further action, such as disciplinary charges, should be pursued.
Te Whatu Ora Group’s director of operations for Auckland, Mike Shepard, apologized to the patient, stating that they have reviewed her care and implemented improvements in their systems and processes to prevent similar incidents in the future. He also emphasized the rarity of such incidents and expressed confidence in their surgical and maternity care quality.
