In a startling medical mishap at an Auckland hospital, a woman discovered that a surgeon had left a device the size of a dinner plate inside her abdomen after she gave birth via Caesarean section.
This discovery was made a staggering 18 months after the initial operation at Auckland City Hospital.
Throughout this excruciating year and a half, the woman endured severe pain and sought help from multiple doctors.
However, it wasn’t until a CT scan was conducted that the shocking truth came to light, leading to outrage and demands for accountability.
Health Board’s Initial Defense Crumbles
Initially, the Auckland health district board, Te Whatu Ora Auckland, vehemently defended its actions, claiming that reasonable care and skill were exercised during the procedure.
However, health regulators swiftly condemned the public hospital system, asserting that it had utterly failed the patient.
New Zealand’s Health and Disability Commissioner Morag McDowell scathingly stated that the care provided fell below the appropriate standard because the device had not been identified during routine surgical checks, resulting in it being left inside the woman’s abdomen.
Hospital staff had no explanation for how the device ended up there or why it went unnoticed before closure.
Apology and Promise of Improvement
Mike Shepard, Te Whatu Ora Group’s director of operations for Auckland, later issued an apology to the woman after regulators criticized the health board.
He mentioned that they had reviewed the patient’s care, resulting in improvements to their systems and processes to reduce the chance of similar incidents happening again.
He also reassured the public that such incidents were extremely rare, expressing confidence in the quality of their surgical and maternity care.
The Nature of the Alexis Wound Retractor
The Alexis wound retractor, a large transparent plastic device suspended between two plate-sized rings, is used to hold open surgical wounds during the operation.
During a Caesarean section, it is typically removed after closing the uterine incision. The challenge in this case was that the device is ‘non radio-opaque,’ meaning it could only be identified through the more sophisticated three-dimensional CT scan.
Recurring Safety Concerns
This incident marks the second time in just two years that a foreign object has been left inside a patient at an Auckland hospital, raising serious concerns about patient safety.
The Commissioner pointed out that the Auckland District Health Board had previously breached the code of patient rights in 2018 after a similar incident involving a swab left in a woman’s abdomen post-surgery. Following that incident, the board had promised to enforce its ‘count policy’ to ensure meticulous accounting of every item used during procedures.
However, McDowell claimed that some surgeons had not even read the policy at the time of the woman’s C-section.
Wider Concerns and Implications
This alarming incident in Auckland highlights a broader issue of foreign objects being left inside patients during surgical and medical care.
In the UK, surgeons faced a record number of such incidents in recent years, with 291 ‘finished consultant episodes’ in 2021/22.
These objects can include swabs, gauze, or even surgical devices like drill bits.
Such incidents are categorized as ‘never events’ by the NHS, signifying their gravity and preventability.
Patients’ Rights and Preventative Measures
Rachel Power, chief executive of the Patients Association, emphasized the importance of implementing preventive measures to avoid never events.
She noted that the physical and psychological effects of these incidents can have long-lasting impacts on patients.
While acknowledging the challenges faced by the NHS, she stressed that never events should not occur if preventative measures are in place.
High Incidence of Never Events in the NHS
In England, there were 407 never events recorded in the NHS from April 2021 to March 2022.
These included instances where vaginal and surgical swabs were left inside patients, along with other objects such as wire cutters, scalpel blades, and drill bit parts.
The recurrence of such incidents highlights the need for continued vigilance and improved safety protocols in healthcare settings.