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A woman who believed she was getting a hysterectomy got an entirely different surgery - without her consent, the health watchdog says.
The Health and Disability Commissioner said the woman had agreed to a hysterectomy due to pelvic organ prolapse six months prior.
But the surgery - done in 2014 at a public hospital which the report did not name - was changed just prior to the woman entering the operating theatre.
She had already been premedicated when she signed a consent form agreeing to get an implant made of surgical mesh instead.
Deputy Commissioner Rose Wall said the woman had no understanding of the procedure that was done.
"The standard of care was not met for the patient - as she clearly wanted and expected a hysterectomy at the time," Wall said.
"She did not get a hysterectomy but instead underwent a procedure involving surgical mesh."
Wall said the timing of the change in surgical plan was "entirely inappropriate".
The woman was alone, prepped in her surgical gown and just outside the theatre room.
She was "pressured and nervous".
"In my view, anticipating that a consumer is in a position to make an informed choice and give informed consent in such a circumstance is a fundamental failing, and should not have occurred in any circumstance."
The consultant obstetrician and gynaecologist said they believed the woman was aware that she would not be having a hysterectomy.
They said that the surgery involved surgical mesh, and that there was a discussion with the woman prior to the surgery to repeat the consent and the specific risks of pelvic organ prolapse surgery.
The woman said she was no longer able to work after increasing symptoms of PTSD after the surgery.
She made a complaint to the Health and Disability Commissioner in 2019 after five years of ongoing problems.
The doctor who did the work is no longer practising in New Zealand.
Wall recommended if the doctor was to practice in New Zealand again, they should implement a system to ensure all treatment options and their associated risks were discussed clearly with patients and documented.
She also recommended the doctor consider how they can improve the informed consent process to ensure patients are provided with sufficient time to fully consider the information they are entitled to, before seeking their consent.
Rest home inadequately managed woman with "black and rotting" foot
Meanwhile, a rest home had been found to have not properly cared for a resident whose foot was "black and rotting".
A report from the HDC said the woman had not been referred to a wound clinic until three months after the wound on her foot was first noticed.
She died of sepsis two days later.
The rest home had been found in breach of the Code of Health and Disability Services Consumers' Rights for not referring the woman earlier.
Aged Care Commissioner Carolyn Cooper said systemic issues were to blame.
"The care home's systems were inadequate to support the woman's timely care, intervention, and referral to more specialised care," Cooper said.
However it has implemented several changes since then, including a wound care policy review, additional staff education and streamlining the referral process.
Ultrasound not followed up
A doctor had been found to have not followed up with a patient who had been referred for an ultrasound, which led to a diagnosis of stage four cancer a year later.
Another report from the HDC said a woman in her 60s was given a voucher for the scan by her GP after post-menopasual bleeding in 2019.
However she did not undergo it as she had the impression it was optional, and the bleeding was nothing to be concerned about.
The woman was later diagnosed with stage four endometrial cancer.
The GP was found in breach of the Code of Health and Disability Services Consumers' Rights for not ensuring the woman had undergone the scan.
The centre has since updated its process for the voucher system, which included a reminder to be sent every time a patient is referred for an ultrasound scan.