A woman’s worsening illness and severe pain following a hysterectomy was caused by a surgical swab left inside her, but it remains unclear how it happened.

The Deputy Health and Disability Commissioner has called it a clear demonstration of a systems failure in that counting surgical swabs “clearly failed” in this instance, and that the healthcare provider had breached the Code of Health and Disability Services Consumers’ Rights.

Dr Vanessa Caldwell said in findings released today that the incident highlighted the need for “hyper-vigilance” during surgery.

The incident at Manukau SuperClinic hospital in December 2021 has prompted a list of recommendations including that Health NZ Counties Manukau audit 20 patients’ records from the past three months, to identify compliance with the gynaecology service’s (swab) count policy, and conduct a refresher training session for existing staff on this policy.

The unnamed woman underwent an elective laparoscopy, bilateral salpingectomy, and total hysterectomy at the hospital.

Health NZ noted that during the surgery there was a slight complication which meant that the surgeons had to re-perform the procedure to close her vaginal vault.

The woman began to bleed and steps were taken to control it. Health NZ said it was common to use swab sponges, which include surgical swabs, and later said it was possible that a sponge could have been left while performing the re-look laparoscopically.

However, at the time the surgical count, including swabs, was completed and documented as correct.

But in the days after the woman left the hospital she noticed a slightly unusual discharge and experienced lower abdominal pain, hot flushes, and a reduced appetite.

On December 18, she went to an urgent care clinic and was given antibiotics but no internal examination was done because she said that “the pain was too extreme”.

The pain worsened overnight, and after self-examining using a mirror, she saw what looked like a yellow cloth protruding from her vagina. When she tried to pull it out, she suffered “significant umbilical pain” so she stopped.

She then telephoned Healthline and was advised to go straight to the hospital for assessment of any infection.

A vaginal speculum examination was completed in the Emergency Department and a gynaecologist found and removed a surgical swab that had been retained inside her vagina.

She was readmitted to hospital for observation, given antibiotics and had an abdominal X-ray to exclude any further foreign bodies.

A member of the gynaecology team visited the woman in hospital and apologised for what had happened.

A consultant and a manager at the gynaecology outpatient clinic then met with the woman to discuss what had happened and the investigation that was to follow.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell. Photo / James Gilberd Photography Ltd

The woman and her husband were then given a formal apology by clinical staff.

In her report into the care provided, Dr Caldwell said the event of a surgical swab being left inadvertently is a “Never Event” - something that should never occur and signifies an adverse event that is “unambiguous, serious, and usually preventable”.

However she was unable to make a factual finding as to how and at what point the surgical swab was left inside the woman.

Dr Caldwell said according to policy, primary responsibility for the surgical count procedures lay with the scrub and circulating nurses.

“However, in my view, this error is the responsibility of all staff involved in the surgery, who were required to ensure that this did not occur, and it is also the responsibility of Health NZ, who provided the overall service.”

Dr Caldwell said that while Health NZ said the surgical counts were completed and documented fully, she considered that the swab being left behind was evidence that there was a failure in the system.

She also noted it was possible that part of the “count policy” had not been adhered to, in that an item placed into a wound temporarily during surgery and which was intended to be removed before cavity closure or skin closure, must be acknowledged and recorded.

“In any event, I am critical that this ‘never event’ occurred. I also acknowledge that it caused unnecessary harm to the woman and prolonged her recovery process,” Dr Caldwell said.

She commended Health NZ on its actions once it became aware of the incident, such as extending apologies and undertaking an adverse event review to try to identify the cause of the error.

“Clearly, this event has been taken extremely seriously, with all surgeons and theatre teams being educated about the case,” Dr Caldwell said.

“I note that several changes and recommendations have been made since this event to reduce the possibility of such an incident reoccurring.”

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.