A woman in her early 50s needed further surgery at least six times and has ongoing health problems after keyhole surgery in 2013.
In a report today, Health and Disability Commissioner Anthony Hill said two unnamed obstetrician gynaecologists and the Southern District Health Board provided poor care, breaching patient rights.
In 2009, the woman expressed concern about what she thought was a family history of ovarian cancer. Since then she'd had a heart attack and been diagnosed with diverticulitis.
She was nervous before the surgery to remove a cyst, but consented to it going ahead on 22 March 2013, Mr Hill said.
By this time, the obstetrician gynaecologist, Dr C, had received results indicating a low risk of cancer, but he could not recall if he discussed these with the patient.
The surgical procedure was complicated because of adhesions. Both the woman's bladder and bowel were injured. The former was detected and repaired in theatre at the time, but the bowel damage was not discovered until three days later.
After surgery, Dr C handed over to the second obstetrician gynaecologist, Dr B, and others, but the woman was in pain and nauseous.
It was suggested to Dr B several times that she might have bowel damage, but he failed to order investigations. Finally, three days after the initial surgery, a laparotomy revealed two holes in the bowel. She went on to have a colostomy and further surgery two days later.
Mr Hill said Ms A, who complained later, required further surgery at least six times to repair damming from the initial surgery. "She has had many ongoing health issues."
He said he was concerned that Dr C proposed surgery to Ms A early in March 2013 "without the knowledge of important clinical factors (the tumour-marker result and a qualified risk of malignancy) - factors that were relevant to a preoperative discussion and Ms A's consideration of whether or not to have surgery".
The technical difficulties experienced in the first surgery were "highly predictable", but Dr C "did not appreciate or think critically about the potential surgical difficulties he might face given Ms A's history of extensive adhesive damage", the commissioner said.
Dr C failed to comply with professional standards and did not keep clear and accurate clinical and surgical records.
After the operation, there was a delay in recognising Ms A was not recovering as well as expected and that she might have a bowel injury. Despite suggestions of a potential bowel injury, Dr B made a decision not to review her or refer her for surgical review.
Mr Hill said the Southern DHB had overall responsibility for the "series of deficiencies in care".