A woman who was put under anaesthetic so a gynaecologist could examine her vagina woke up to find that an operation had been carried out - one she had not consented to.
The doctor involved and the district health board - Wairarapa DHB - have been ordered to apologise to the woman and have had to make changes to their patient consent forms and policies as a result.
The incident came to light after the patient laid a complaint to the Health and Disability Commissioner about the services she received by the gynaecologist and the DHB.
Neither the woman nor gynaecologist have been named in the report, released by the HDC, for privacy reasons.
Documents show that in 2016 the woman presented with what is described in the report as problematic symptoms.
• Hamilton gynaecologist accused of performing STI test on woman during first date
• Gynaecologist Naylin Appanna suing private hospital for 'wrongful' suspension
• The struck-off gynaecologist Bill Cosby turned to for Quaaludes
• Gynaecologists' reveal what they're really thinking during an examination
"The gynaecologist proposed to examine the woman's urethra and bladder under general anaesthetic and, if indicated, perform surgery on her anterior vagina," the document says.
The woman signed a Wairarapa DHB-issued consent form for an examination under anaesthetic, cystoscopy inject local anaesthetic, steroid to perineum and refashion anterior vagina procedures to be carried out.
The consent form included the standard clause: "I understand that procedures additional to that specified above may be carried out if it is in my/the patient's best interests and can be justified for medical reasons."
During the procedure, the doctor noticed some abnormalities and performed a Fenton's procedure - removal of scar tissue - on the woman's posterior vagina.
"He considered that this might help to alleviate her symptoms," the report says.
'It was distressing to find that I had been cut all over again'
The woman told the commissioner she had not consented to that particular procedure - despite the gynaecologist saying he genuinely believed he had the consent to do so.
"I did not go into this surgery expecting in any way to be cut near the perineum area and had not prepared logistically or psychologically for the healing time involved with this," the woman told the commissioner.
"It was distressing to find that I had been cut all over again, when I hadn't expected to be.
"It was more healing and time off work than I had expected."
Expert advice to the commissioner showed that the Fenton's procedure is not a common operation and should be used "sparingly".
The expert also advised that there needed to be a pre-operative discussion about that particular procedure.
The advice was that, in this case, there was no emergency need for the doctor to perform the Fenton's procedure on the woman.
ACC claim made a year later
In 2017, the woman submitted a claim to the Accident Compensation Corporation for treatment injury.
Documents show she told ACC that she continued to suffer "significant perineal pain" and that she believed the pain had been exacerbated by the Fenton's procedure. The claim was accepted.
Ultimately, the commissioner believed there had been a breach.
"The commissioner found the gynaecologist in breach of Right 7 (1) of the Code of Health and Disability Services Consumers' Rights (the Code) for having performed the procedure without the woman's informed consent and found Wairarapa District Health Board vicariously liable for the gynaecologist's breach."
A number of recommendations were made by the HDC; including that the gynaecologist apologise to the woman involved, review the effectiveness of his changes to practise and undertake education on informed consent.
The Wairarapa DHB was also encouraged to apologise to the woman and review its training on informed consent that it provides to its staff.
"During the investigation, Wairarapa DHB revised its standard consent form and prepared a provisional revised consent form."