Six weeks later, it was found by the GP, who removed what smelled “like a dead body”.
Findings released today by the Health and Disability Commissioner revealed how the woman cried and was “scared to death” that it could lead to serious illness or infection – or worse, death – because of the negligence.
Deputy Health and Disability Commissioner Rose Wall was “highly critical” that the maternity service did not have a relevant policy in place for ensuring potentially “retainable items” were accounted for.
Deputy Health and Disability Commissioner Rose Wall said the maternity care provided by Health NZ Capital, Coast and Hutt Valley in 2021 had been a distressing experience for the woman and her family.
She found Health New Zealand Te Whatu Ora failed to provide services to the woman with reasonable care and skill. It also failed to provide services which minimised potential harm, leading to two breaches of the woman’s rights under the health consumers’ code.
Wall did however commend the health provider’s prompt decision to investigate the cause, and take responsibility for the errors identified, in a serious adverse event report.
Care transferred to obstetrics team
The woman’s care was transferred from her midwife to the hospital obstetrics team when further delivery assistance was needed.
An episiotomy was carried out by an obstetrics registrar to help with delivery.
As the incision was being repaired, the doctor was called away.
When she returned, she continued what she had been doing but forgot to remove the packing, Wall said.
“Further, at the relevant time, Health NZ did not have a specific count policy regarding management of accountable items for the maternity service,” she said.
In the days after, and despite multiple checks by a midwife who handled follow-up care, there were no concerns expressed or detected.
When the woman started complaining of pain, she was prescribed analgesia (painkillers).
Further checks by the midwife did not detect any redness or swelling.
When the woman reported some tummy cramps, and because she was still tender, Voltaren and paracetamol were prescribed.
GP finds source of problem
Over the next few weeks, she started developing other symptoms but the source of the problem wasn’t detected until she visited her GP, who found the retained pad and removed it with forceps.
The doctor responsible apologised in person. The woman later received a formal apology and follow-up care, including a scan.
In her conclusions, Wall was critical that, at the time, the maternity service did not have a relevant policy in place for ensuring potentially “retainable” items were accounted for.
“I am highly critical of this as, in my view, this put patients at risk,” she said.
Wall said at a minimum, the policy should have included a robust system for monitoring the number of swabs used during a procedure.
Delivery of the woman’s baby was transferred from her midwife to the hospital obstetrics team when further assistance was needed. The incident happened after the doctor repairing an incision was called away to another patient. Photo / 123rf
She said the adverse event report by Health NZ identified that staffing levels were short at the time and accordingly, Wall was concerned that systems issues may have contributed to the error, especially because a senior medical officer was called away at a critical moment.
Wall said the error was the responsibility of the hospital’s obstetrics team and of Health NZ, which provided the overall service to the woman, and was ultimately responsible for ensuring that policies and procedures were in place to minimise the possibility of a swab being left behind.
New measures in place
She said the woman suffered unnecessary complications and a protracted recovery as a result.
Health NZ has since put in place a list of measures to prevent a recurrence, including the introduction of orange high-visibility wristbands to identify those who had swabs or packing in situ.
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.