A neurosurgeon has been criticised by the Health and Disability Commissioner for performing brain surgery in the wrong place.
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The commissioner, Anthony Hill, said the man was having surgery to remove cancer in his brain.
The surgical site was identified using a guidance machine and markings were made on the man's skin.
Once the initial incision was made, it became apparent that the guidance machine was inaccurate and the incision had been made in the wrong place.
The skin markings had washed off and could not be used as a guide.
The neurosurgeon then extended the bone opening into what he thought would be the correct area.
However, the operation had to be stopped and further attempts to remove the tumour were considered to be too risky.
Mr Hill accepted that while any neurosurgeon could have made the error, it was still unacceptable.
The man died some time later as a result of the cancer.
Mr Hill has recommended that the neurosurgeon apologsie to the man's family.