Surgical instrument left in man's abdomen, Waitematā DHB in breach of health codes - report

The commissioner found several failures within the DHB's staff and systems.
The commissioner found several failures within the DHB's staff and systems. Photo credit: Getty Images

A report has found the Waitematā District Health Board in breach of health codes after a surgical instrument was left in a man's abdomen. 

An Alexis wound retractor - a tool used to hold open a surgical wound - was left inside the man following emergency surgery to treat a perforated colon in 2018. 

Two weeks after the surgery the man began to suffer from stomach pain and nausea and was admitted to hospital. 

The wound retractor was found inside the man using imaging. It had been displaced and was pushed fully into his abdomen, which had not been noticed at the end of his initial colon surgery.

Health and Disability Commissioner Morag McDowell on Monday released a report finding the Waitematā DHB in breach of the Code of Health and Disability Services Consumers' Rights for its failures in providing care to the man. 

The commissioner found several failures within the DHB's staff and systems including a collective failure by the surgical team to recognise the initial displacement of the surgical instrument.

Waitematā DHB was found to have a practice of excluding Alexis wound retractors from their surgical count - a process of counting instruments to ensure none had been accidentally left displaced inside the patient. McDowell considered this to be "very risky". 

There was also an "apparent lack of understanding" by some staff about the purpose of the surgical count policy and a "lack of critical thinking by some staff about the risks of not counting all items". 

The report said these failures represent "systematic issues" of which McDowell says the DHB is responsible for. 

"This case highlights the risk in assuming that a highly unlikely event - in this case, the retention of a large surgical instrument - would not happen. It also reinforces the importance of routine safety checks during surgery," McDowell said. 

She recommended Waitematā DHB establish a process for ensuring that the list of countable items in the surgical count policy remains current; conduct an audit to ensure compliance; provide training to staff on the importance of vigilance and provide a written apology to the man's family. 

Last year a woman was left "traumatised" after a surgical swab was mistakenly left in her abdomen for almost a month following a surgery at Auckland Hospital. 

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. 

DHBs have also faced recent sterilisation scares. In 2019 the Southern, Waikato and Canterbury DHB's were found to have exposed at least four patients to unsterilised surgical equipment during surgery. 

Another 50 patients may have had inadequately sterilised surgical tools used on them at Hawkes Bay Hospital in 2019.