Key Takeaways
- A woman was left with vaginal packing inside her body for six weeks after giving birth due to a medical error.
- The packing was discovered during a post-natal checkup with her GP, who removed it with forceps.
- The incident was investigated by the Health and Disability Commissioner (HDC), which found a breach of the Code of Health and Disability Services Consumers’ Rights.
- The hospital has apologized and implemented changes to prevent similar incidents in the future, including the development of a perineal trauma and repair form.
- The doctor who performed the surgery and the attending midwife have also apologized and made changes to their practices.
Introduction to the Incident
A disturbing medical error was recently reported, in which a woman was left with vaginal packing inside her body for six weeks after giving birth. The incident occurred at a public hospital operated by 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. However, the doctor attending to her forgot to remove the packing, leading to a series of unfortunate events.
The Aftermath of the Incident
In the following weeks, Mrs. A experienced tenderness and stomach cramps, which were monitored by an attending postnatal care midwife. The midwife believed that these symptoms were consistent with a usual postnatal scenario following a difficult birth. However, it wasn’t until Mrs. A visited her GP for her baby’s six-week checkup that the packing was discovered and removed. The GP documented that a retained pad was discovered and removed with forceps, and Mrs. A and her husband reported that the smell was like a dead body coming out of her. The couple was understandably concerned about the possibility of resulting serious illness or infection.
Investigation and Findings
The Health and Disability Commissioner (HDC) investigated the incident and found that there was a breach of the Code of Health and Disability Services Consumers’ Rights. The Commissioner, Rose Wall, stated that Mrs. A had the right to have services provided to her with reasonable care and skill, and that Health NZ had an organizational responsibility to provide a reasonable standard of care to its patients. The investigation revealed that, at the time, the maternity service did not have a relevant policy in place for ensuring potentially "retainable" items are accounted for. The Commissioner was critical of this lack of policy and recommended that a robust system be put in place to monitor the number of swabs used during a procedure.
Response and Changes
Following the discovery of the swab, the clinical head of the obstetrics and gynaecology department at the public hospital met with Mrs. A and her husband and offered an apology, as well as providing an assurance that 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. The hospital also stated that they would provide audits of these forms to the HDC to ensure compliance with the process when counting in and out any vaginal packing. The doctor who performed the surgery apologized in person and accepted responsibility for forgetting to remove the swab, and the attending midwife made changes to her practice as a result of this incident.
Conclusion and Recommendations
The incident highlights the importance of having robust policies and procedures in place to prevent medical errors. The HDC’s investigation and recommendations aim to ensure that similar incidents do not happen in the future. The hospital’s apology and commitment to implementing changes are a step in the right direction, and it is hoped that this incident will serve as a learning experience for healthcare providers. The development of a perineal trauma and repair form and the implementation of audits to ensure compliance with the process are positive steps towards preventing similar incidents. Ultimately, the goal is to provide a high standard of care to patients and to prevent harm from occurring.