A woman has been left partially paralysed and in pain after a surgeon put screws in her spine in the wrong place.
A report by the Deputy Health and Disability Commissioner states an orthopaedic surgeon performed an initial surgery on the woman, in her 60s, in a private hospital in 2017.
A CT scan after a fall the following month revealed an error with the screws.
The woman continues to live with pain and lower body paralysis despite multiple procedures by the surgeon in public hospitals to correct it.
Her daughter said her mother's "life changed forever at the hands of a qualified surgeon".
"She is now a T1 Paraplegic fully dependent for all life cares, described by the Spinal Unit Consultant as a 'tragic surgical outcome'."
The deputy commissioner Rose Wall said the surgeon failed to treat the woman with reasonable care and skill.
She was also critical of the district health board for a delay in getting help from its Acute Pain Service team.
Wall said the Medical Council should consider reviewing whether the surgeon is competent.
The surgeon said they accepted "responsibility for the very sad outcome" and offered sincere regrets to the woman and her family.