The anaesthetist faulted for her care of a Greymouth teenager, who died after a nurse disconnected his oxygen monitoring machine, is now practising in the North Island.
None of the three health workers criticised in an official investigation into Matthew Gunter's death has been charged with criminal offences, but the police say the file remains open.
The anaesthetist was found by Health and Disability Commissioner Anthony Hill not to have provided appropriate care for Matthew in November 2012 when she was a locum at Greymouth's public hospital.
The Nelson College boarder, from Greymouth, died in Christchurch Hospital intensive care unit from a brain injury linked to a build-up of fluid in his lungs causing a lack of blood flow and oxygen after undergoing surgery to remove his appendix at Grey Base Hospital.
Mr Hill names neither patient nor doctor in his report. Nor does he name two nurses who he found had, like the anaesthetist, breached the code of patients' rights. He has referred one of the trio - the children's ward night nurse - to his prosecutor for a decision on whether to charge her with professional misconduct.
The anaesthetist did not respond to Herald interview requests yesterday. But the general manager of the hospital where she practises said he was not aware of her connection to the Greymouth case.
"I'll have to have a look at it."
Health workers can be charged with manslaughter and lesser criminal offences relating to their patients, but this has become rare since a 1997 bill boosted the test in the Crimes Act from ordinary negligence to gross negligence.
Under the amendment, health workers must be proven to have made a "major departure from the standard of care expected of a reasonable person" if a manslaughter charge is to stick.
Matthew's mother, Heather Gunter, said Mr Hill should publicly name the three practitioners as part of their accountability.
Mr Hill indicated on Radio New Zealand he did not name the night nurse because she might go before the tribunal, which could choose to suppress her name and he ought not frustrate that legal process.
He withheld the other two names in line with his office's 2008 policy not to name individual health workers unless they posed a risk to the public, ignored commissioner recommendations or were frequent offenders against the code of patients' rights.