Nurses' failures led to a surgical rope dressing being left in a woman's breast for three months, the Health and Disability Commissioner has found.
Health and Disability Commissioner Anthony Hill said the error was due to failures by district nurses, and the Auckland District Health Board was responsible.
The woman, who had recently given birth, had had an abscess drained and Aquacel rope was used to pack the 3cm-deep wound afterwards.
Mr Hill said the end of the rope should have been left visible on the skin for removal later, but this did not occur, and the nurses assumed, without asking the woman, that she'd removed it.
Instead, it went undetected for three months, while the wound became infected and painful.
Mr Hill said poor record-keeping by the nurses meant he was unable to determine why the rope was left in the woman's breast.