A woman needed to be readmitted to hospital after it was discovered a surgical swab had been left inside her vagina following a procedure.
The woman’s ordeal was detailed in a Health and Disability Commissioner (HDC) report investigating what happened after the December 2021 surgery.
On December 2, 2021, the woman checked into the Manukau SuperClinic hospital to undergo an elective laparoscopy, bilateral salpingectomy, and total hysterectomy, the report said.
She was discharged two days after the surgery following an “uncomplicated recovery”.
A few days after her release from the hospital, the woman noticed a “malodorous vaginal discharge” and was suffering from lower abdominal pain, hot flushes, and had a reduced appetite.
On December 18, she checked into an urgent care clinic where she was given antibiotics, but the pain worsened overnight.
After self-examining using a mirror, the woman noticed what looked like a “yellow cloth protruding from her vagina”.
“When the woman tried to pull this out, she suffered significant umbilical pain, so she stopped,” the report read.
The woman then called Healthline, who told her to go straight to the hospital to determine if she had an infection.
During a gynaecological examination — 17 days post-surgery and having experienced symptoms for one week — a doctor found and removed a surgical swab that had been left in her vagina.
She was readmitted to the hospital and was given an x-ray and antibiotics.
While being questioned by the HDC, Health NZ said a count of equipment during the woman’s surgery “was completed and documented as correct”.
“The count sheets for both the top and bottom trolleys showed that a total of 40 small swabs and five large swabs were used during the procedure.”
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found that “at some point in the surgery, a swab was placed into the woman’s vagina and not accounted for”.
She found Health NZ in breach of the woman’s right to have services provided with reasonable care and skill.
Caldwell called it “a clear demonstration of a systems failure”.
“In that the surgical count process, which is designed to ensure that all surgical items used during a procedure are removed and accounted for, clearly failed in this instance.”
Caldwell said Health NZ had given a “prompt response” to the incident, quickly apologising to the woman.
“Clearly, this event has been taken extremely seriously, with all surgeons and theatre teams being educated about the case.
“I note that several changes and recommendations have been made since this event to reduce the possibility of such an incident reoccurring.”
Caldwell had made several recommendations, including that Health NZ perform a random audit of 20 patients’ records from the past three months and conduct training for staff on the Count Policy.
