A woman was left feeling “scared to death” after vaginal packing was mistakenly left in her body for six weeks before being found at a post-natal GP check.
The woman’s ordeal was detailed in a Health and Disability Commissioner (HDC) report released today after an investigation into what happened at the public hospital operated under Te Whatu Ora Health NZ Capital, Coast and Hutt Valley in 2021.
The woman – known as Mrs A – underwent an episiotomy following the birth of her daughter, and vaginal packing in the form of a swab and tampon was inserted to apply pressure to the site and control bleeding.
During the surgery, the doctor attended to another patient on the ward and, on their return, continued to repair the perineum but did not remove the packing.
Deputy Health and Disability Commissioner Rose Wall’s report noted that, at the time, Health NZ did not have a specific count policy regarding management of accountable items for the maternity service.
Mrs A continued with postnatal care at the hospital and at home in the following days, including check ups from an attending postnatal midwife.
The HDC said during the following weeks she reported experiencing some “tenderness” and stomach cramps, which an attending postnatal care midwife monitored and said in her experience “appeared to be consistent with a usual postnatal scenario following a difficult birth”.
Packing discovered after six weeks
When Mrs A went to see her GP for the baby’s six-week check, she raised some of the symptoms she had been experiencing with the physician, who documented that – on examination – a retained pad was discovered and removed with forceps.
Mrs A and her husband, Mr A, told the HDC: “[We] discovered a left out pad [the] size of half of an ‘arm’ inside [Mrs A’s] vagina and when [the GP] removed it, the smell was like a dead body coming out of her.”
The couple said Mrs A was “scared to death that it could lead to some serious illness/ infection or worse death due to this negligence of duty”.
The Commissioner found there to be a breach of the Code of Health and Disability Services Consumers’ Rights, as Mrs A “had the right to have services provided to her with reasonable care and skill”.
“Ultimately, Health NZ has an organisational responsibility to provide a reasonable standard of care to its patients. That did not occur in this case, as Health NZ failed to ensure that a vaginal swab was removed following the delivery of Mrs A’s baby.”
‘Distressing experience’ – Commissioner
Rose Wall acknowledged it was “a distressing experience for Mrs A and her family”.
“Following discovery of the swab left in situ, understandably Mrs A was concerned about the possibility of resulting serious illness or infection.
“In reviewing the circumstances of this incident, I am critical that, at the time, the maternity service did not have a relevant policy in place for ensuring potentially ‘retainable’ items are accounted for.
“At a minimum, the policy should have included a robust system for monitoring the number of swabs used during a procedure. Had such a system been in place at the time, likely this would have avoided the issues that arose for Mrs A.”
Changes implemented
Following the discovery of the swab, the clinical head of the obstetrics and gynaecology department at the public hospital met with the couple and offered an apology, as well as providing an assurance this would not happen again.
Health NZ Capital, Coast and Hutt Valley developed a perineal trauma and repair form as a result of this incident and placed it in all clinical areas in maternity wards.
Wall recommended audits of these forms be provided to HDC, to ensure compliance with the process when counting in and out any vaginal packing. She also urged the hospital to consider how new staff would be oriented in the “perineal trauma and repair” procedures to achieve 100% compliance.
The hospital said: “We wish to express our sincere apologies to Mrs A for the care she received while under our services. It was never our intention to cause harm.”
The doctor who performed the surgery also apologised in person, and accepted responsibility for forgetting to remove the swab.
The attending midwife advised HDC that she had made changes to her practice as a result of this incident, particularly regarding the use of swabs when prescribing antibiotics.
