Dinner-plate-sized tool left in New Zealand woman after C-section

A New Zealand woman visited multiple doctors for help with severe abdominal pain after having a Caesarean section in 2020. But when she underwent a CT scan about a year later, doctors had no problem identifying the cause of her agony, according to a new report.

The scan found that during the woman’s C-section, doctors had left a piece of equipment about the size of a dinner plate in her abdomen, the report alleges. About 18 months after the woman’s original procedure, doctors removed an Alexis wound retractor – a soft, round plastic device that retracts the edges of an incision during surgery – from the woman’s abdomen, the report states.

On Monday, New Zealand’s health and disability commissioner ruled that the medical group that performed the C-section – governmental agency Te Whatu Ora – breached the country’s code of patient rights by leaving the device inside the woman’s abdomen and failing to make a record of it.

“The care fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman,” commissioner Morag McDowell wrote in her decision. “Systems should have been in place to prevent this from occurring.”

McDowell recommended that Te Whatu Ora apologize to the woman and adjust its policies to ensure that staff members record the use of Alexis wound retractors in future surgeries.

Mike Shepherd, the interim leader of the medical group’s hospital and specialist services, has apologized to the woman and her family, he said in a statement to The Washington Post.

“This has resulted in improvements to our systems and processes which will reduce the chance of similar incidents happening again,” Shepherd said. “We acknowledge the recommendations made in the Commissioner’s report, which we have either implemented, or are working towards implementing.”

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