A woman's surgical wound that was slow to heal was found to have had a 5cm piece of rope dressing left behind, according to a Health and Disability Commissioner's report.
Commissioner Anthony Hill says the woman had surgery to drain an abcess in a breast after she gave birth to her first child.
She was referred to the district nursing service for ongoing management of the wound, which was packed with a dressing called Aquacel rope, the end of which was meant to remain outside the wound.
However, when the end of the rope wasn't visible, the woman was assumed to have removed it, which she hadn't.
The wound was slow to heal and, after several months, the woman was referred to the surgical team for review.
During surgical excision of the wound, a 5cm piece of Aquacel rope dressing was discovered, which had prevented the wound from healing.
Mr Hill found that the Aquacel rope was not used appropriately and the wound was not investigated adequately.
He was critical that the district health board's wound assessment form was not designed to give an objective indication of wound progress over time.
He also said the district nurses were not recording objective assessments of the woman's wound consistently.
After the event, the district health board undertook a review of policy, standard operating procedures and process, and implemented changes.
Mr Hill recommended that the DHB provide a report confirming the implementation of changes and also apologise to the woman.