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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.”
In 2020, 11 medical professionals performed the C-section on the woman, who was in her 20s, at Auckland City Hospital, according to McDowell’s report. A surgeon made an incision in the woman’s abdominal cavity and attempted to use an Alexis wound retractor, which can help prevent infections, the decision states. But the surgeon decided the retractor was too small, so it was removed and replaced with a larger version, the report alleges.
While the retractor would have normally been removed before the skin was stitched closed, it was left in the woman’s abdomen, the report says. Te Whatu Ora did not require the use of Alexis wound retractors to be recorded during procedures because of the low risk of the devices being forgotten inside of patients, the report alleges.
In the 18 months after her C-section, the woman went to both her general practitioner and the Auckland City Hospital’s emergency department with stomach pain, according to the decision. While the retractor wasn’t seen on X-rays, a CT scan found the device lodged inside her abdomen before it was surgically removed. The woman filed a complaint to the health and disability commissioner in 2021, the report states.
The commissioner had previously advised the medical group to revise its policies for recording the use of surgical tools and equipment after doctors left a swab in a woman’s abdomen during a 2018 surgery. McDowell said in a news release that she was “disappointed” the problems persisted.
“While individuals hold some measure of accountability in this respect, this is a systems failure,” McDowell wrote in her decision.
Te Whatu Ora directed staff members in a June 2021 memo to record the use of Alexis wound retractors during procedures, according to McDowell’s statement.
The medical group told the health and disability commissioner that there was “insufficient basis to find that there was a failure to exercise reasonable care and skill in this case,” the report states.
Te Whatu Ora said there was also a lack of expert evidence to conclude that its staff broke the country’s code of conduct for treating patients, but McDowell wrote that it was clear the surgery fell short of expectations.
“There is substantial precedent to infer that when a foreign object is left inside a patient during an operation,” she wrote, “the care fell below the appropriate standard.”
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