Only 18 months after her delivery, Alexis’ wound retractor – a soft tubal instrument used to hold open surgical wounds – was removed.

After suffering severe pain for several months, the woman visited several doctors until a CT scan revealed the problem.

The public hospital system failed the patient, according to health regulators.

At first, Auckland’s health district board Te Whatu Ora Auckland argued that reasonable care and skill had not been exercised.

In a report released on Monday, New Zealand’s Health and Disability Commissioner disagreed.

As a result of the [retractor] not being identified during routine surgical checks, it was left inside the woman’s abdomen, Morag McDowell said.

The staff involved have no explanation for how the retractor ended up in the abdominal cavity or why it was not identified prior to closure, she said.

Alexis wound retractor is a large object made of transparent plastic attached to two rings. In a C-section, it is usually removed after the uterine incision is closed and before the skin is stitched.

The item was discovered on a CT scan, but X-rays could not detect it since it is non-radiopaque.

A device had been left in a patient at an Auckland hospital for the second time in two years.

Ms McDowell said the hospital should have had protocols in place to prevent the incident, which caused “a prolonged period of distress” for the woman.

As a result of the pain, the woman, in her 20s, consulted her GP “a number of times” in the 18 months after giving birth in 2020.

According to the commissioner, the Auckland District Health Board had already violated patient rights in 2018, when it left a swab in a woman’s abdomen after surgery.