A surgeon and a medical centre who accidentally left a gauze swab inside a woman after her surgery have been found in breach of the Code of Health and Disability Services Consumers' Rights.

The patient, a 51-year-old woman, had surgery to treat fibroids and a 3cm cyst in her uterus that had caused continuous bleeding and discomfort.

In a report released today, Health and Disability Commissioner Anthony Hill found the theatre nurses did not complete the initial count check of swabs and anything sharp used in the operation before it began in late-January 2017.

The registered nurses did not record that a gauze swab used to control the bleeding caused by the removal of a uterine polyp, despite the fact that one of the nurses recalled hearing the surgeon announce that it had been inserted.


At the end of the surgery, the surgeon did not confirm the status of the count of swaps and sharps used, a required step of the medical centre's court policy.

"In this case, a pattern of individually unremarkable sub-optimalities (communication,
policy clarity, and policy compliance) led to an oversight — the retention of the swab," Hill said.

"All of these factors matter. This case is an example of the need to be constantly vigilant to ensure communication is effective, policies are clear, and that they are complied with."

Four days after her surgery, the patient began to feel "extremely unwell" and it was later discovered that a gauze swab had been left inside her vagina.

While on the operating table, the patient had a sudden spasm of her vocal cords, which was treated with medical and intubation through the patent windpipe.

The operation's scrub nurse told the HDC the post procedure count "wasn't fully completed due to [her] being distracted by ongoing concern over the patient".

The surgical recovery report of the procedure noted it was "a difficult procedure both
surgical and anaesthesia".

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The doctor said the ultimate responsibility lay with her.

"[T]he ultimate responsibility lies with the surgeon and I have no hesitation in accepting that I should have checked that the [gauze] swab had been removed."

She also acknowledged that she did not follow up with the nurses to make sure the swab had been removed, but said that as the insertion of the gauze swab was not recorded, the final count may have identified the missing swab.

Hill also found that staff were unsure about their roles and responsibilities in the counting process, and that the medical centre's count policy lacked sufficient detail.

Hill recommended that both the surgeon and the medical centre provide a written apology to the woman.

He also recommended that the medical centre report on its use of the Surgical Safety Checklist and carry out a random audit to identify compliance with its count policy, which is then to be provided to the HDC.

The location of the medical practice was not named in the HDC's report.