A doctor and medical centre have been faulted by the healthcare watchdog after they failed to give correct advice to a woman who later required a radical hysterectomy.
The woman had a history of cervical abnormalities but also had two cervixes leading to the mix-up.
While both cervixes were tested by the family doctor, the GP only initially received results for one which indicated that it was all clear.
When the medical centre received the other test, which indicated abnormalities, it was misfiled as a duplicate.
Even though the woman had a history of abnormalities, she was expected to wait six months to receive a colposcopy when it should have been graded as semi-urgent and conducted between one to three months.
When she received one privately, cervical cancer was found which required a hysterectomy.
She is now in remission.
Health and Disability Commissioner Anthony Hill criticised the family doctor for failing to discuss specialist care with her earlier and accurately following up test results.
He also said the medical centre should have had a tracking system in place at the time of the tests.
Mr Hill recommended that both should provide the woman a written apology.