The Health and Disability Commissioner has found a gynaecologist failed to provide follow-up advice to a patient who later died of cervical cancer.
The 39-year-old woman saw the gynaecologist, whose name will not be released, because she experienced bleeding about four months after giving birth.
The gynaecologist physically examined the woman and took a full history, but did not take a cervical smear or perform a colposcopy, which might have indicated the presence of cancer.
The doctor said the bleeding was due to hormonal changes arising from breastfeeding.
His documentation shows he failed to advise the woman to see her GP if her symptoms persisted, nor did he inform the woman's GP of the need for further evaluation.
The woman was diagnosed with cervical cancer eight months later and died the following year.
The Health and Disability Commissioner recommended the gynaecologist apologise to the woman's family and review his practice.