A gynaecologist treated a patient's endometriosis using ablation - cutting and burning the tissue in surgery - despite her refusal to consent to it before she went under the knife.
In a report released today, Health and Disability Commissioner Anthony Hill found the obstetrician and gynaecologist that performed the surgery and the Capital & Coast District Health Board failed to respect the woman's refusal of the treatment.
The DHB and doctor involved were found in breach of the Code of Health and Disability Services Consumers' Rights.
In 2015 the patient, in her 30s, required surgery for suspected endometriosis - a debilitating disease which causes tissue similar to the lining of the uterus to grow in other areas of the body.
A health professional, she had researched the different treatments available to offer relief from the worsening pain.
Following an unsuccessful trial of a Mirena IUD to ease her pain, the patient and gynaecologist agreed that a laparoscopic surgery was the next step.
During the minimally invasive surgery, the endometriosis is removed from the uterus by excision - cutting out patches of the tissue using small instruments - by ablation - using an electrical probe to cut and burn the tissue - or by using both methods.
But the patient had already decided that she did not want ablation used in her surgery, and had told the doctor this.
There was no record on her medical notes that ablation had been discussed or that the patient had refused to have it during the surgery.
Her doctor told the HDC that he routinely performs ablation in his practice.
"He said that his usual practice is to tell patients that although excision of endometriosis is his treatment of choice, ablation may need to be performed in specific cases," the decision stated.
"Dr B stated that he informs patients that there is no way of knowing whether ablation will be required until after the laparoscopic surgery has commenced, because the exact location of the endometriosis lesions becomes apparent only during the surgery.
"He said that each lesion is evaluated and a decision made on whether to use excision or ablation based on the proximity of the lesion to major blood vessels."
At a pre-surgery appointment, the patient again said that she did not consent to ablation, with a junior doctor recording this in her clinical notes.
But the gynaecologist did not read her clinical notes before the surgery and treated the patient using ablation.
When the woman awoke to be told endometriosis had been found and treated with ablation and excision she was shocked, upset, and alone, she told the HDC.
"[T]he bottom line is that I did not consent to a treatment that I subsequently had. I had the right to refuse that treatment regardless of the surgeon's preference and my right to choose was taken away from me," she said.
• Endometriosis: The brutal disease no one talks about
• Woman's heartbreaking photo illustrates life with endometriosis
• Premium - Middlemore Hospital: Women with endometriosis living in extreme pain; top doctor says 'we don't have enough' to help
Hill criticised the doctor for his failure to read the patient's clinical notes before her surgery, or record important discussions about consent, including the woman's concerns about ablation.
"Informed consent is at the heart of the Code," Hill said.
"It was [the woman's] right to make an informed choice about the procedure she was to undergo, and not to be treated with ablation when she had refused it."
He found that the doctor did not pay enough attention when the woman told him that she did not want to have ablation performed.
The doctor was ordered to provide a written letter of apology to the patient.
A copy of the HDC investigation will be sent to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Medical Council of New Zealand, which has been advised of the doctor's name.
The Capital & Coast District Health Board was also found to have failed to provide the patient with appropriate care, as its systems for informed consent didn't provide adequate guidance to staff.
Hill recommended the DHB also provide a written apology to the woman and to provide evidence to HDC about improvements to its informed consent processes.