A man in his early 50s had skin cancer diagnosed by a laboratory but nothing was done for more than a year because of weak recall systems at his plastic surgeon's clinic.
The Health and Disability Commissioner, Anthony Hill, says in a report made public today that the surgeon and the clinic, of which the surgeon is a director, breached the code of patients' rights.
The patient, unnamed in Mr Hill's report, saw the surgeon, on referral from his GP, about lesions on his nose, scalp, left cheek and lower back. He had a family history of skin cancer.
The surgeon later performed biopsies of the lesions, with the intention of removing all of the suspected cancer tissue on the cheek and back, and just enough for diagnosis from the nose and scalp.
When the man returned for the removal of sutures a week later, the lab report on the histology - tissue samples - was not available.
The nursing note of the consultation states that he was advised to contact the clinic by the end of the week if he had not heard anything from the surgeon.
The man, however, recalls being instructed to wait for further advice.
The lab report, which arrived a day after the sutures-removal consultation, diagnosed basal cell carcinoma, a type of skin cancer.
The commissioner's office said: "Despite the man requiring follow-up he was not informed of the histology results and no follow-up was arranged."
More than a year later the man, seeking travel vaccinations, saw a GP who noted three areas suspicious for basal cell carcinoma on his scalp.
The GP sought the lab report and a week later met the patient again and told him of its cancer diagnosis. He referred the man to a skin specialist for surgery.
The plastic surgeon does not remember how the error in not informing the patient of his test results occurred, but said it was likely he signed off the test result remotely and either did not print the report or it was printed but mis-filed.
He accepted he signed off the lab report but did not take further action.
Mr Hill said that by failing to inform the man of his abnormal test results the surgeon breached the code.
The commissioner found that the lack of safeguards in the clinic's systems contributed to the man receiving sub-optimal care.
Mr Hill asked the clinic to audit records of patients with abnormal test results back to August 2012 to ensure they have been informed and if necessary had appropriate follow-up organised.
The surgeon has apologised in writing to the patient and Mr Hill asked the clinic to do likewise.