Two nurses failed to document and follow up with a man whose bleeding lesion turned out to be a fatal malignant melanoma.
A Health and Disability Commissioner's report into the care of the 65-year-old man shows he was treated for a bleeding lesion in 2011 by a rural health nurse.
Anthony Hill said the nurse did not follow it up and when the man was back in hospital for a hip operation a registered nurse also noted the lesion.
Mr Hill said the registered nurse did not objectively assess and record details about the lesion nor the man's pain.
It was not until the man told a physician about it, that it was discovered to be a malignant melanoma, which he died from 14 months later.
The commissioner has made recommendations about better communication, documentation and training for suspicious moles and skin lesions.