WHOOPS

Dinner Plate-Sized Device Accidentally Left Inside Woman After C-Section

The error wasn’t discovered for 18 months.

A health board in New Zealand has apologized to a patient after a report found that a surgical device “about the size of a dinner plate” had been inadvertently left inside her abdomen following a cesarean section birth. The Alexis retractor, or AWR, was left inside the mother after her child was delivered in Auckland in 2020. The tool—which is used to draw back the edges of a wound during surgery—was not detected by X-rays the mother received after complaining for months of chronic pain. It wasn’t until an emergency room visit in 2021, around 18 months after the c-section, that an abdominal CT scan found the AWR and it was removed. New Zealand’s Health and Disability Commissioner Morag McDowell said in a report that Auckland’s district health board’s care “fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman.”