A surgeon removing fibroids from a woman's uterus burnt the patient three times after leaving a hot piece of surgical equipment on her belly.
The doctor only noticed the burns after smelling something strange while carrying out the elective gynaecological surgery.
The Health and Disability Commissioner deemed the surgeon breached the Code of Health and Disability Services Consumers' Rights.
Names have been removed from a report about the incident, published today, to protect the privacy of those involved.
On December 17, 2018, a woman underwent gynaecological surgery to remove fibroids from her uterus and it was held at a private hospital.
During the procedure, a diathermy pencil was used to cut and coagulate tissue.
A diathermy pencil is a hand-held unit which uses an alternating electric current of very high frequency to emit intense heat when passed from the pencil to the patient.
The pencils come with a holster for safe placement when it is not in use.
However, during the surgery, the surgeon placed the pencil on the woman instead of in the holster, causing three deep burns on her abdomen.
After discovering the burns, the surgeon made sure they were exposed and cooled, before being reviewed by a plastic surgeon.
The operation was completed without further incident, the Commissioner's report found.
The woman who was burnt told the HDC it will take her longer to recover from her burn wounds than the actual operation.
"[These events] have influenced my day-to-day life but also I will now have to live with [the burns] the rest of my life both physically and mentally," she said.
"Plus, I may potentially have to undergo another operation to amend the error, which may leave me [with] scarring in other places, further time off work, and maybe further issues."
The woman complained to the HDC about the services provided by the surgeon.
After investigating the incident, the Commissioner recommended the surgeon review her practice and attend a workshop about achieving safer practice.
The surgeon also had to pen a written apology to the woman.
The Commissioner thought the private hospital was not in breach of the Code, instead, it was a case of individual failure.