A woman was not told for a month of a medical mishap that left her eye permanently damaged.
The Health and Disability Commissioner said a senior ophthalmology trainee touched the woman's retina with an instrument during an eye procedure.
Anthony Hill said the doctor had not told the woman sufficiently before the operation that he was a trainee and that he would be carrying out the surgery.
Mr Hill said the woman was not in a position to give informed consent.
He said the doctor also failed to inform her of any increased risks resulting from his doing the surgery, and did not record and disclose the mishap.
Mr Hill recommended the trainee and his superior attend courses on informed consent and open disclosure.