A dentist pulled the wrong tooth out of a 15-year-old girl - and immediately put it back in.
The dentist was asked to remove three baby teeth in April last year. He took out two, but then, by mistake, removed an adult tooth instead of the third baby tooth.
The family dentist, "Dr B", was removing the teeth an orthodontist had required to be taken out, according to a report made public today by Health and Disability Commissioner Anthony Hill.
The girl, "Ms A", needed complex orthodontic treatment. She had several congenitally missing teeth, an incorrect bite and other dental issues.
The dentist said, "It was only upon its extraction that I then realised by the length of the root this mistake had occurred. My immediate response was to re-implant the tooth without delay."
The reason the third baby tooth was not extracted at this stage was to provide support to the reimplanted tooth.
The report says the dentist "removed teeth 53 and 63. However he removed tooth 26 by mistake instead of tooth 65. Tooth 26 is immediately behind tooth 65".
"He realised his error immediately and reinserted the tooth 26 back into the socket.
"On April 21st [2015, Dr B] started root canal treatment on tooth 26. [Dr B] has referred [the girl] to a specialist endodontist to complete the root canal work on tooth 26.
"Currently tooth 65 still has not been removed and the orthodontist is considering options.
"ACC [the Accident Compensation Corporation] has been informed and have accepted the claim as a treatment injury. [Dr B] has offered to pay any additional fees in the attempt to keep tooth 26 and if it becomes unsaveable in the short or long term he has offered to pay the cost of an implant."
Mr Hill found the dentist had breached the code of patients' rights by failing to provide services with reasonable care and skill.
He recommended the dentist apologise to the girl and that the Dental Council consider if a review of the dentist's competence is warranted.