An obstetrician and gynaecologist has been criticised for a lack of caution and not seeking advice when she perforated a woman's bowel while performing a hysterectomy.
The doctor mistakenly made a 10 to 12cm perforation in the woman's bowel while attempting to identify the Pouch of Douglas, an extension of the peritoneal cavity while performing the vaginal hysterectomy.
She then sought the assistance of her superior to perform an abdominal hysterectomy while a third surgeon performed a loop colostomy to repair the woman's bowel.
Health and Disability Commissioner Anthony Hill found in a report released on Monday that there was no evidence the OB/GYN had notified the woman that she made a mistake and perforated her bowel during the initial surgery.
He said she had been involved in "prior adverse events" at the hospital and noted her failure to seek assistance from a more senior colleague and switch to an abdominal procedure earlier before finding she breached her duty to provide reasonable care an skill.
The OB/GYN has since apologised to the woman and will be required to undergo a review of her competence with the Medical Council of New Zealand.