The woman had taken Estelle in the past, but her GP at the time deemed Estelle to be unsuitable because of the woman's risk factors and had instead prescribed the minipill which did not carry the same risks.
The woman transferred her primary care to a medical centre where she saw a GP, who prescribed Estelle for the woman but did not document it.
The GP also did not document any discussion of the risks associated with Estelle or the alternative options for contraception or treatment of PCOS.
Over the next three and a half years, the first GP and two other GPs at the medical centre provided repeat prescriptions of Estelle for the woman.
Over that time, the woman's risk factors increased, the decision said.
No medical review was undertaken to determine whether Estelle was suitable, and there was little documented evidence of a discussion with the woman about her risk factors.
The woman later underwent a surgical procedure to remove her gallbladder at the local hospital but developed a blockage of an artery in her lung after surgery and died.
The commissioner found the first GP breached the code by reinstituting Estelle for the woman without a proper reassessment of her suitability, or recording her blood pressure.
The GP was also found to have breached the code by failing to inform the woman of her risk factors or suitable alternatives to Estelle, and by failing to comply with professional standards in respect of her documentation.
The medical centre was found to have breached the code by failing to ensure that the woman's ongoing use of Estelle was adequately monitored through regular, specific medical reviews and counselling on her risk factors.
The other two GPs' care was found to have fallen below an appropriate standard but did not breach the code.
The commissioner recommended the first GP and the medical centre provided written apologies to the woman's family but no penalties were ordered.
