A doctor tested a woman's cervix, but then failed to act on the abnormal lab result until queried by the National Cervical Screening Programme more that six weeks later.
The unnamed overseas-trained doctor has been found in breach of the code of patients' rights by Health and Disability Commissioner (HDC) Anthony Hill, in a decision made public today.
Cervical smear testing is done to detect cells that could indicate cancer or potentially pre-cancerous abnormalities.
The doctor has been told to write an apology to the woman, who was 38 at the time. He also must make a random audit of his clinical records to ensure that patients' test results in the last two years have been followed up properly and that the patients have been advised of the results.
The cervical smear was taken on October 11, 2013. The lab results were reported to the doctor's medical management system inbox eight days later. He told Hill's inquiry he did not recall seeing the result in his inbox, but thought he must have viewed and then probably filed it.
On December 5, 2013 the screening programme asked if the woman's referral for colposcopy - cervical examination with a magnifying instrument - had been made. A nurse at the medical centre messaged the doctor about this and he immediately made the referral. He did this without looking at the woman's notes and he failed to discuss the follow-up with the woman, earning additional criticism, on top of that for failing to make the referral in the first place.
An unnamed district health board wrote to the woman, "Ms B", on December 12, 2013, to advise of the colposcopy appointment, but the woman did not receive the letter.
"Ms B told HDC," Hill said, "that the first time she learnt of her abnormal cervical smear, taken on 11 October 2013, was when she received a call from the DHB on 23 June 2014, the day of her colposcopy appointment."
The colposcopy occurred and a biopsy was taken of a cervical lesion. Lab analysis of the biopsied tissue confirmed a low-grade lesion and the woman's primary care doctor was asked to do another smear test in six months.
She complained to the medical centre the next day, but received no further feedback about it and she later complained to the commissioner's office.
Hill said the doctor stated he understood that if he took a smear, the results would be followed up by the centre's nurses.
"He said he was not familiar enough with the system to know that the results would not be seen by the nurses, and that the results would be filed back into the office Medtech system only through his 'inbox'."
But the company that owns the centre told the commissioner each health practitioner was responsible for managing results of tests he or she had ordered, unless a nurse was specifically asked to follow up.
Hill made "adverse comment" about the company for not ensuring the doctor - who had received orientation - had an adequate understanding of its results-tracking processes and failing to respond to the woman's complaint.