The Office of the Health and Disability Commissioner today released a report finding a district health board (DHB) in
breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for mistakenly leaving a surgical swab
in a woman’s abdomen during surgery at a public hospital.
The woman had symptomatic artery disease and claudication (pain caused by obstruction of the arteries) in her right
thigh. She underwent an elective aorto-right iliac bypass graft (placement of grafts on the aorta and the right iliac
artery to bypass a blood vessel that is blocked or narrowed, to increase blood flow to the legs). This was performed by
the hospital’s vascular service.
The surgery was reportedly performed in accordance with the vascular service’s standard procedure. The nurses counted
items used during the surgery as required, and no items were unaccounted for. The surgeons were notified of, and
acknowledged, the correct count. The nurses stated that they took this process seriously.
However, during the surgery, a swab was left in the woman’s abdomen, which was not discovered until almost four weeks
later. The DHB conducted a clinical case review but was unable to explain how the swab was retained, given that the
surgical count was recorded as correct.
Former Commissioner Anthony Hill found that the DHB failed to provide services with reasonable care and skill. He was
highly critical that the error occurred, and considered the error to be the responsibility of the DHB and all the staff
involved in the surgery.
Mr Hill was also critical of the DHB’s count policy and discrepancies in training for different teams at the time of
events, and considered that improvement in these areas may help to reduce any unnecessary risk and opportunities for
error in future.
"The DHB needed to ensure that its system provided [the woman] with safe care of an appropriate standard," said Mr Hill.
"Somehow, that system failed [the woman], 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]."
Mr 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 recommended that the DHB consider how new medical surgical staff will be oriented to the
Count Policy; provide the results of its yearly audit, including details of any changes made as a result and any
specific education provided to staff; and provide a letter of apology to the woman.
The full report on case 18HDC02321 is available on the HDC website.