A man went days without diagnosis of a condition that left him paralysed from the waist down after his doctor's office forgot to tell him about his blood results.
A new report from Health and Disability Commissioner Anthony Hill has found an otherwise healthy 21-year-old man was not told about serious problems with a blood sample by his GP, and eventually ended up a tetraplegic after an emergency trip to the hospital days later.
The patient reported flu-like symptoms to the doctor who took a blood sample in May 2011.
But when the test came back the next day with serious problems in the results, the doctor forgot to tell his nurse to contact the patient with the urgently needed information.
"I am at a complete loss as to why this omission occurred. It may have slipped my mind as a result of consulting with other patients that morning after I reviewed the results," he told the commissioner.
Within a couple days the man found he could not walk and was taken to a hospital by his father, after he which began to deteriorate into a serious condition as doctors urgently tried to figure out what was wrong.
He was eventually diagnosed with a severe inflammatory disease that damaged nerve fibres in the brain and was left with tetraplegia.
Mr Hill ordered the doctor to apologise after finding that there was not a proper system at the GP's office to inform patients about results.
The doctor said he had spent a significant amount of time thinking about his work since the incident.
"I am extremely sorry for what happened to [him] and the significant impact that this has had on his and his family's lives."
The patient now lives in a residential care facility.
A Medical Council assessment of the doctor found there were no concerns about competence.