A doctor has been reprimanded for forgetting to send a referral letter to a specialist for a patient who was later found to have bowel cancer.
Health and Disability Commissioner Anthony Hill details the case in a report released on Monday.
A 62-year-old woman with several health problems complained to her doctor in 2009 about rectal bleeding and discomfort.
She saw her unnamed GP several times over nine months and was prescribed a treatment for haemorrhoids but never physically examined.
At the last of these consultations the GP referred her patient for a colonoscopy but forgot to print or send the letter.
The woman went to hospital in severe pain just over a month later and tests revealed an advanced cancerous tumour in her colon.
Anthony Hill says the GP failed to examine the woman, failed to keep records, failed to send the referral and had no back-up reminder system for such referrals.