A doctor who failed to indicate the extent of a cancerous white lesion on a man's tongue has been noted as not providing services to the man with reasonable care and skill.

The Whanganui District Health Board said it accepted that it did not provide services to the patient with reasonable care and skill, a report by the Health and Disability Commissioner has revealed.

The report stated that an oral and maxillofacial surgeon was in breach of the Code of Health and Disability Services Consumers' Rights for failing in the management of a man's tongue lesion.

The surgeon undertook a biopsy of the lesion and "the histology report following the biopsy indicated squamous cell carcinoma in situ (cancer), incompletely excised".

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"The surgeon should have undertaken a further biopsy or referred the man to a multidisciplinary team, however the surgeon continued to monitor the man over the next five months.

"The surgeon did not inform the man of this diagnosis or discuss management options with him. The surgeon then noted that the white lesion had returned, and that an additional biopsy would need to be performed under general anaesthetic," the report said.

The man underwent a third biopsy and results again showed cancer in the tongue.

Following this biopsy the surgeon did not inform the man of this diagnosis or discuss management options with him, even though he saw the man on two further occasions.

"The surgeon did not ask the man about the pain in his tongue following the biopsies.

"He then referred the man, approximately two years after he first saw him, to the Radiation/Oncology Clinic at another DHB for additional follow-up."

During his care of the man the surgeon kept minimal, and largely illegible, clinical records and operation notes, the report said.

"Dr B's written notes were illegible, that there were inadequate handwritten records, and that there was no typed correspondence from Dr B's outpatient clinics or operation notes."

It was recommended the DHB provide an apology, undertake an audit of the surgeon's clinical records, and establish a formal process to ensure quality oversight within the Dental Unit.

It was also recommended that the DHB undertake a review of the patient booking system to ensure that patients are not discharged from its system when referred to another practitioner.

"The surgeon was referred to the Director of Proceedings for the purpose of deciding whether any proceedings should be taken. "