Two health professionals failed to monitor and review a bleeding mole on a 65-year-old man, who later died of melanoma, the Health and Disability Commissioner found.
The Health and Disability Commissioner (HDC) Anthony Hill found a registered nurse and a rural nurse specialist failed to provide medical care for the man.
The man was found to have a large bleeding lesion on his upper back, three months after a hip replacement operation.
The rural nurse specialist documented this and advised the man to have it checked by a surgeon at an upcoming consultation.
However, there was no record the surgeon had reviewed the mole.