An unnamed Auckland surgeon breached a patient's right by inserting a contraceptive device without her consent, the Health and Disability Commissioner has ruled.
The procedure, which happened during a pregnancy termination, is detailed in a report by Health and Disability Commissioner Anthony Hill.
Mr Hill said the intrauterine device (IUD) was inserted immediately after the termination at the Epsom Day Unit in 2010, without the patient's knowledge.
She had repeatedly said she did not want an IUD and that she intended using condoms.
She found out about the IUD two-and-a-half years later, when she was unable to get pregnant.
The surgeon said he did not know how it happened but believed a nurse put the IUD on a trolley and he inserted it thinking it was what the patient wanted.
Mr Hill said consent was vital, and the surgeon needed to ensure he had this.
"It is not good care to insert an IUD in a person who has not consented. It is not good care to have that person leave without knowing and to have received advice," he said.
"It is clear that we need systems that support the effective and reliable delivery of good care. That did not occur in this case."
He also blamed inadequacies in the checking system used by the Auckland District Health Board at the time.