The complaints commissioner at the Centre hospitalier de l'Université de Montréal (CHUM) has ruled that an incident where a 33-centimetre metal plate was left in the abdomen of a cancer patient was not caused by negligence on the part of staff.

Commissioner Geneviève Frenette wrote in her report that "it seems that no negligence was involved in the event, but rather that it was a failure of procedure."

As a result, the hospital is pledging to update its procedures during surgery.

When the error occurred, at the beginning of each operation, an initial count was made of surgical objects being used and a recount was done at the end.

The report states that the metal plate was mistakenly accounted for in a final recount even though it was "still in use."

Despite the "failure of procedure," the report cleared all CHUM staff of any wrongdoing.

Medical instrument montreal woman notre-dame hospital

Sylvie Dubé underwent a second surgery on May 25 to remove the metal plate just a few days after another round of chemotherapy. (Radio-Canada)

'The pain was too intense'

For her part, patient Sylvie Dubé isn't pleased with the report's findings.

She recalled the pain following her surgery at Notre-Dame Hospital as severe.

"It felt like I had been stabbed," she told Radio-Canada. "The pain was too intense."

Dubé has ovarian cancer, and the plate was left inside her body during her hysterectomy in May. In the two months that followed, she complained to hospital staff about severe pain, but was told it would be normal to experience some post-surgical discomfort.

It was only when she went in for an X-ray in June that the metal plate was discovered.

"With the conclusion of this investigation and her cancer coming back, Sylvie is pretty well drained," said Alain Cadieux, her partner of 36 years.

Sylvie Dubé

Dubé said that the pain was intense but hospital staff told her it would be normal to experience pain post-surgically. (Radio-Canada)

He thinks that living with a metal object in her belly didn't do much to facilitate her recovery last spring.

"She spent several months in extreme stress and pain," he said.

Despite the disappointing outcome of the report, Cadieux says his partner is well positioned to restart her next round of treatment. 

"She now has a pivot nurse and a new doctor."

She will start a new round of chemotherapy this coming Wednesday, which is expected to last six months.

Procedural changes coming

In light of the investigation, some procedural changes will be put in place to ensure the same type of incident doesn't happen again, CHUM said.

"There is a lot of awareness that has been made at the staff level," said Dubé. "It will help improve the procedure. That was the purpose of the complaint."

As part of the new rules, a count of surgical instruments is done while the wound is being closed and any item missing is circled on the list. When the incision is fully closed, another instrument count will be done.

The hospital says it is committed to implementing this into all operating rooms.

Dubé said that while she received an apology from the nurses at a recent meeting with management, she's hired a lawyer to help negotiate a compensation.

While forgetting to remove instruments during surgery and other medical procedures is rare in Canada, Quebec is the province with the highest number of recorded cases.

The national average is about 8.6 cases out of 100,000, but Quebec reports 11.6 cases out of 100,000, according to the Canadian Institute for Health Information.

With files from Radio-Canada's Davide Gentile