The report quotes the woman as saying she was not made aware her bowel had been perforated.
"At no time did [Dr A] advise either me or my husband that there had been a treatment injury caused by her to my bowel. As I was on morphine a lot of the time I didn't comprehend most of what was happening around me ... The focus was on the pelvic adhesions not the 10 centimetre bowel injury. At this stage it was both my husband's and [my] understanding that I ended up with the emergency operation because of these [the pelvic adhesions], not because of the treatment injury caused by [Dr A]."
The doctor states that she repeatedly told the patient what had happened to her.
"I returned to the hospital later in the evening on the day of her surgery, to inform the patient of the outcome of her surgery and the complication that had occurred.
"I was very aware that the medication used for anaesthesia and pain control could affect [Mrs B's] cognition and memory and, therefore, I repeated the conversation regarding the surgery and complication on several occasions."
Health and Disability Commissioner Anthony Hill said the doctor has been found in breach of Health and Disability Services Consumers' Rights. He particularly criticised her lack of caution and failure to seek advice from a senior colleague earlier in the procedure.
"The OB/GYN's failure to seek advice and convert to an abdominal procedure earlier, together with her mistaken incision of incorrectly identified tissue amounted to a serious departure from expected standards and a failure to provide services to the woman with reasonable care and skill."
The doctor had been involved in prior adverse events at the hospital. Hill has recommended that should she return to practise in New Zealand that the Medical Council of New Zealand undertake a review of her competence before issuing a practising certificate.
Hill also recommended that the DHB introduce a credentialing process for advanced surgical procedures.