A GP has been found in breach of the health and disability code after he failed to respond to an elevated test result for a patient who now has terminal cancer.
The patient, referred to only as Mr B, had been a patient of the general practitioner's for many years.
In 2012, when he was 60 he went to the GP complaining of reduced energy and breathlessness.
The doctor, named only as Dr A, ordered a prostate-specific antigen (PSA) test which was due anyway.
The test result came back slightly above the normal range.
"Dr A filed the elevated PSA result as 'normal' and did not discuss the result with Mr B," Health and Disability Commissioner, Anthony Hill said in his findings.
Mr B returned to the doctor in July 2014 with urinary complaints and another PSA test revealed Mr B was significantly above the normal range.
Dr A still did not tell Mr B immediately about the previous elevated result.
Mr B was referred to an urologist and was diagnosed with aggressive prostate cancer, which had spread.
"Mr B's prognosis is that his condition is terminal and he is receiving ongoing oncology care," Mr Hill said.
He found Dr A failed to recognise the elevated 2012 result and to take appropriate action.
"A failure that resulted in Mr B missing an opportunity for early diagnosis of his prostate cancer."
He found that breached the the Code of Health and Disability Services Consumers' Rights.
Dr A said he was "at a loss" as to why he filed the result as normal.
"I remain deeply disappointed over my omission."
Mr Hill recommended Dr A apologise to Mr B and his wife, and that an audit be undertaken of his records to ensure all patient test result received in the past six months have been followed up and communicated properly.