A new report has revealed the "shock" and "upset" a woman felt when she awoke from surgery to find her gynecologist had used a treatment she had refused consent for beforehand.
On Monday the Health and Disability commissioner Anthony Hill released a report into the incident, which occurred in November 2015 when the woman required an operation for suspected endometriosis.
During consultations with her gynecologist, the woman said she didn't want the treatment of ablation (cutting and burning using an electrical probe) used during the operation. She preferred to be treated by surgical excision (cutting with surgical instruments) instead.
Before the surgery, which occurred in the Capital and Coast DHB, the woman also reiterated that she did not give her consent to ablation to a junior doctor who recorded it in her clinical notes.
"When she woke from surgery she was told that endometriosis had been found and treated with ablation and excision," Hill's report said.
"She said that she was shocked, upset, and alone, and felt that she was not in a position to complain having just woken up from surgery."
The gynecologist had failed to read the notes and said he "doesn't recall" the woman's previous refusal.
He said he had not intended to harm the woman or disrespect her choices.
"Had I appreciated that [she] did not consent to ablation, I would not have performed it, regardless of whether I believed it was in her best interests or not," he said.
The new report found he, along with the Capital and Coast District Health Board, had breached the Code of Health and Disability Services Consumers' Rights.
"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."
Hill also found the DBH failed to provide the woman with appropriate care because its systems for informed consent did not provide adequate guidance to staff.
The Capital and Coast DHB said: "We sincerely apologise for any distress that the outcome of this operation caused for [the woman] and any sense of mistrust or vulnerability it created for her".
