A GP installed a contraceptive device in a woman's uterus without working out that she already had one.
The doctor has been faulted by Health and Disability Commissioner Anthony Hill who, in a report made public today, says she breached the code of patients' rights by failing to treat the woman with reasonable care and skill.
The woman had had a copper intrauterine contraceptive device (IUCD) placed in 2007 and it was due to be removed in May 2012.
In January 2012 she went to her medical centre and received treatment for a vaginal infection. She told the nurse she had an IUCD in place and that it was due for removal in five months. The nurse recorded this in the patient's notes.
The woman saw her GP about a month later and recalls telling her of the existing IUCD, but the GP said she was not aware of the device and did not ask the woman about contraceptive use and history.