Two surgeons, an anaesthetist and a district health board have been censured for failing a man who died from complications during surgery he may not have needed.
Health and Disability Commissioner Anthony Hill investigated the death of the 74-year-old man who had surgery to remove gallstones at Gisborne hospital.
He suffered severe complications and died the following day.
Mr Hill found that the surgeon who performed the 2011 operation breached her duty of care by failing to properly inform her patient about his treatment options and not getting informed consent.
She also showed a "lack of reasonable care and skill" in going ahead with surgery, which had been delayed for six months, when the man had other health problems.
"In those circumstances, the surgeon should have proceeded with more caution," Mr Hill said.
The surgeon's approach to the man's post-operative condition also lacked caution, he said.
Mr Hill made adverse comment about another surgeon and the anaesthetist involved in his care.
The Tairawhiti District Health Board also came in for heavy criticism for sub-optimal documentation, pre-operative process, consent to treat processes as well as the "lack of discernible leadership, coordination and critical thinking in the clinical team".