The decision comes after a gynaecologist inserted a surgical mesh product into a woman in 2013, which later gave her "significant complications".
The health commissioner has found a doctor breached the rules in regards to a surgical mesh procedure he performed.
It relates to a surgery carried out by Dr B, a gynaecologist, to insert a mesh implant in Ms A to treat her stress incontinence and vaginal prolapse in 2013, at a public yet unnamed hospital.
Rose Wall, deputy Health and Disability Commissioner (HDC) released her report on Monday, saying the gynaecologist gave insufficient information about the procedure and consent process.
"Based on the information available, I am not satisfied that the gynaecologist informed the patient of the risks specific to the surgical mesh procedure, including those of mesh erosion and chronic pelvic pain."
Wall found the doctor breached the 'code of health and disability services consumers rights' (the Code), in relation to the insertion of a surgical mesh product, called transobturator tape (TOT).
Surgical mesh, such as TOTs, are medical implants used "when repairing weakened structures" to provide extra support, according to Te Manatū Hauora / The Ministry of Health.
Mesh comes in two types - absorbable or non-absorbable - the latter remains in the body as a permanent implant.
Ms A also underwent pelvic floor repair and a total vaginal hysterectomy.
Afterwards, she suffered "significant complications" and doctors found the mesh had eroded through her vaginal wall.
The TOT was eventually removed.
Following surgery, Ms A's constant medical exams to find out what was causing her symptoms had dented her dignity and privacy, she said, undermining her whakapapa Māori, rangatiratanga, and stripping her mana.
Wall found the gynaecologist breached the Code due to not giving adequate information on risks or consent ahead of surgery.
"It follows that, without the necessary information, the patient was not able to make an informed choice and give informed consent to the surgery," she said.
Wall said the doctor also had bad record keeping and didn't give alternative treatment options.
"I am critical that the surgery was documented poorly, and that this made it difficult to assess the standard of the surgical technique," Ms Wall said.
The gynaecologist has since made several changes to his practice, such as no longer using TOTs, and improving documentation.
The report found Te Whatu Ora was not at fault, however the health agency has since developed online courses for its junior doctors about informed consent.
The hospital in question has also developed new patient booklets on treatment options for stress incontinence and pelvic organ prolapse, which Ms A and Doctor B helped with too.
Wall recommended the doctor give a written apology, complete an online course on consent, reflect on his record-keeping, and ensuring all treatment options and risks are discussed clearly with patients.
