The Health and Disability Commissioner is warning people with melanoma they must insist on a follow up care plan after the cancer is removed.
A report into the death of a man, 45, from the cancer found no care plan had been put in place after he had a melanoma removed by his GP.
He first had a lesion removed by his GP in 2008, but returned a year later when he discovered a lump under his armpit.
The GP referred him to a surgeon to have the lump removed but failed to mention that the man had previously had melanoma, as had other people in his family.
The man organised to have the lump cut-out following a trip overseas, but by then it had hardened and spread to his brain, liver and lungs.
He died a few months later.
The Commissioner found the GP, who has since retired, was guilty of breaching the medical code.