A man suffered a more-than two-month delay in getting treatment after a doctor mistook testicular cancer for a cyst.
The doctor - who can not be named for legal reasons - was found in breach for failing to provide services with reasonable care and skill to a man with testicular cancer, Health and Disability Commissioner Anthony Hill found.
Hill instructed the GP to provide the man with a written apology as well as supplying HDC with evidence furthering his education and training regarding testicular masses.
The patient - who had a vasectomy noted in his medical records - presented to the doctor in April 2016 with a lump in his right testicle.
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After examining the testicle, the doctor concluded the lump was an epdidymal cyst.
The doctor told HDC he advised the man to return for a follow up if his symptoms persisted but this was not documented in his notes and the man said he was never told this.
Then, in June 2016, the man saw a different GP at the same medical centre as the cyst had continued to grow and the right testicle was bigger than the left.
The man was referred for a ultrasound, which was carried out three weeks later.
Results from the ultrasound revealed the lump was likely to be testicular cancer and a referral was made for an urgent urology test at the public hospital, which confirmed the findings.
Five days later the right testicle was removed, and a subsequent CT scan revealed lung cancer, which required chemotherapy treatment.
The medical centre was not found vicariously or directly liable for any breach of the code.