It comes two years ago the Herald revealed that $15 million was paid to cancer patients in just five years - after they were misdiagnosed, or not diagnosed quickly enough.
But the payouts came to late for many, this man included.
His grieving widow made a complaint to the HDC saying her late husband's care was not prioritised, even after the error.
The names of the man, his wife and the doctors involved were not published in the report, citing privacy reasons.
The man presented to his GP with pink, elevated and firm nodule on his left front thigh.
He was discovered to have an aggressive and rare form of skin cancer, known as Merkel Cell and had surgery to remove the lump by a cancer team at Taranaki DHB.
A doctor emailed a referral for radiation treatment but the DHB's Telecommunications Department failed to action the specialist referral.
The man did not receive his appointment until some five months after the original referral had been made.
A junior doctor told the man and his wife: "Unfortunately this referral appears to have been lost in the system and no follow-up has occurred. We were very sorry to hear of this and it is most concerning that this has managed to fall through the cracks particularly with him subsequently presenting with a mass in his groin."
He underwent two unsuccessful rounds of chemotherapy before he died a few months later.
In the report, the DHB said it accepted that the referral was not sent to the Radiation Oncology Department mailbox as required.
A DHB spokesperson also said "the inability of hospital staff to assist the man when he was following up on his referral for some four months was not acceptable and very frustrating".
Health and Disability Commissioner Morag McDowell said the DHB did not have robust policies and procedures in place to ensure that it was able to identify when referrals had been missed.
She said the DHB failed to comply with the New Zealand Health and Disability Core standards by not providing the man with the timely, competent, and appropriate services he needed for the treatment of his cancer.
McDowell recommended that the DHB provide a written apology to the man's whānau and report to HDC on the progress it had made in implementing a fully automated referral system.
She also advised the DHB to develop a live auditing system to monitor referrals, provide a summary of its audits of the automated part of its referral system and develop a specific training document for staff for transferring calls to the appropriate departments.
Man in his 20s dying of melanoma after GP failure
In a separate decision released today it was revealed a man, in his 20s and living with Asperger's syndrome, is dying after a GP failed to tell him he had melanoma cancer.
The doctor examined a lump on the man's back and ran some tests. But when the results came back the doctor did not share the results with his patient or recommend a referral to a specialist, the HDC report found.
Deputy Health and Disability Commissioner Rose Wall found the GP in breach of its patient code of rights and ordered the doctor to re-apply for a practising certificate, and provide a written apology to the family.
