A woman has been left "traumatised" after a surgical swab was mistakenly left in her abdomen for almost a month after an operation at an Auckland hospital.
A report into the incident was released on Monday, which found the Auckland District Health Board had breached the Code of Health and Disability Services Consumers' Rights.
The woman, who was in her 40s at the time, underwent surgery at a public hospital to increase blood flow to her legs after suffering from symptomatic artery disease and claudication (pain caused by obstruction of the arteries).
Members of the surgical team described the operation as "uneventful" and the nurses counted the surgical items.
"All relevant counts were performed, and determined to be correct," the report said.
"The surgeons were notified of, and acknowledged, the correct count. The nurses stated that they took this process seriously."
But weeks later the woman reported a lump in her abdomen and pain and unwellness.
After being referred to the emergency department, a CT scan discovered a surgical swab inside her abdomen. She had to undergo a second surgery to remove it.
The woman said in the report that she is still traumatised by the incident and is suffering from the outcome.
Former Health and Disability Commissioner Anthony Hill said the DHB had failed to provide adequate care for the woman.
Hill also criticised it for the count policy and discrepancies in training for different teams at the hospital.
"The DHB needed to ensure that its system provided [the woman] with safe care of an appropriate standard," he said.
"Somehow, that system failed, and a swab was left inside her abdomen... As a result of this, the surgery caused unnecessary harm and a protracted recovery process for [the woman]."
Hill recommended that the DHB mandate that all surgical staff read the Count Policy and ensure that they keep up to date with any changes.
He also advised that the DHB consider new staff learn the count policy and provide the results of the changes in a yearly audit.
