Three doctors at a medical centre have been forced to apologise to a dead man's wife after failing to diagnose him with rectal cancer.
In a report released today, the Health and Disability Commissioner said the GPs failed to think critically.
In February 2018, the man, aged in his 80s, went to his GP after a fall.
The next month, he returned to the GP due to pain near his rectum, tailbone and a change in bowel habits.
The man then had two more consultations about his bowel habits, first with a second GP and next with a third GP at the same practice.
On 5 April, the man had his final consultation with the first GP, and was referred for a colonoscopy.
None of the GPs examined the man's rectum and the referral was deemed inadequate.
In mid April, the man transferred to a public hospital and was diagnosed with rectal cancer.
He underwent treatment but died "a few months later".
The Health and Disability Commissioner received a complaint from the man's widow.
The commissioner, Anthony Hill, said there was a "lack of critical thinking" about alternative diagnoses.
"This report highlights the importance of considering differential diagnoses for a patient's symptoms and of conducting appropriate tests," Hill said in a statement.
"It also highlights the importance of ensuring adequate referral from GPs to secondary care services."
The three doctors were in breach of the health and disability code 4.1: "every consumer has the right to have services provided with reasonable care and skill".
However, the medical centre was found to have not breached the code, as the policies were "appropriate".
Hill said the three GPs at the practice had to give a written apology to the man's wife and have further training in colorectal cancers.
The medical centre, man and location were not named in the commissioner's report to protect privacy.