Director of Proceedings v Health New Zealand – Te Whatu Ora [2025] NZHRRT 19

Director of Proceedings v Health New Zealand – Te Whatu Ora [2025] NZHRRT 19

(10 June 2025)

The Director filed proceedings by consent against Health New Zealand (“Health NZ”) in the Human Rights Review Tribunal (“the Tribunal”) regarding the care provided to the aggrieved person.

In January 2020 the aggrieved person attended a then Auckland District Health Board (“ADHB”) hospital[1] for a scheduled C-section. It was known in advance that the C-section was going to be complex due to the aggrieved person having an anterior placenta previa[2] overlying a previous C-section scar, concerns about placenta accreta[3] and an elevated maternal body mass index.

During the surgery, an Alexis Wound Retractor (“AWR”) was used to draw back the edges of the wound to assist the surgeon’s visualisation of the surgical field. The AWS used was approximately the size of a dinner plate. The AWR should have been removed before the surgeon closed the incision, but inadvertently this did not occur. 

The aggrieved person presented to her general practitioner a number of times over the following 18 months with various complaints, including ongoing abdominal pain since the birth of her child. In late 2020 she was referred to general surgery at Auckland City Hospital to assess a large incisional hernia resulting from her C-section. The retained AWR was incidentally discovered during a CT scan before the scheduled hernia surgery. The AWR was removed during the hernia repair surgery.

The aggrieved person made a complaint to the Health and Disability Commissioner (“HDC”) in June 2021.

At the time of the C-section, the ADHB had a Count Policy for Surgical Procedures (“Count Policy”) to “account for all items used during the surgical procedure and in order to prevent the potential for patient harm because of a retained foreign body”. However, it was not the practice of the operating room nursing staff to include AWRs in the surgical count. Following the discovery of the AWR, a directive was sent to perioperative staff around the inclusion of AWRs in the count, the Count Policy was reviewed, and additional training provided to staff.  

Health NZ accepts that it failed to provide the aggrieved person with services of an appropriate standard and breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (“the Code”). This included responsibility to ensure that appropriate systems were in place to encourage a culture of safety and to support clinicians to carry out their roles safely and effectively. Health NZ also acknowledges the impact of this event on the aggrieved person’s health and wellbeing and the distress caused to her.

The Tribunal was satisfied that Health NZ failed in the care provided to the aggrieved person and issued a declaration that it had breached Right 4(1) of the Code.

The Tribunal’s full decision can be found at:

2025-NZHRRT-19-Director-of-Proceedings-v-Health-New-Zealand.pdf.