The Health and Disability Commissioner has found an obstetrician/gynaecologist breached the Code of Health and Disability Services Consumers' Rights in relation to surgically removing an ovarian cyst.
In a report released on Monday HDC said a woman underwent surgery for what she thought was the removal of a cyst on her right ovary.
During surgery, the specialist found a 30 cm ovarian cyst situated in the lower abdomen, but which unexpectedly arose from her left ovary.
According to HDC, the specialist removed part of the cyst and another senior gynaecologist removed the rest.
Two days later, the woman became very unwell.
She was found to have a pierced bowel which had caused an infection.
An emergency surgical procedure was performed which included removing part of the bowel.
The woman complained to HDC that she had only consented to the removal of the cyst on her right side, and that she'd told her surgeon she was hesitant about surgery on the left side due to previous surgery.
It was later confirmed there was an increased risk of bowel injury due to the woman's previous left-sided surgery, due to scar tissue.
According to HDC, the surgeon was aware this meant increased complexity of surgery.
Health and Disability Commissioner Morag McDowell found the specialist breached the right to advise the woman of the increased risk of injury to the bowel.
"The specialist was aware of the uncertain nature of the cyst's origin, and I would have expected him to communicate that uncertainty to the woman, alongside an explanation that intraoperative findings could necessitate a deviation from the original plan," Mcdowell said in a statement.
"In light of the woman's hesitations about left-sided surgery due to her surgical history, I consider this to be information that a reasonable consumer in her circumstances would expect to receive," she said.
The hospital, where the operation took place has apologised to the woman, and the breached specialist has retired from clinical practice.
He has since provided a written apology to the woman.
