A 78-year-old man did not find out for more than three years that he had cancer because his doctor did not tell him.
In a report today, Health and Disability Commissioner Anthony Hill said an unnamed GP had breached patient rights in several respects.
Mr A went to Dr C in early 2012 with a sore knee. He was also experiencing a slowing of speech and a fizzing feeling in his feet.
Dr C ordered blood tests, and chronic lymphocytic leukaemia was confirmed six days later.
In 2013, Mr A moved to another region and his clinical notes were transferred from his original medical centre to the new one.
Mr Hill said between 2013 and 2015 Mr A consulted with GPs many times. Blood tests were requested regularly and it appears that Mr A's chronic lymphocytic leukaemia (CLL) was being monitored.
Mr A only knew about it on 8 September 2015 when he went to a pre-admission appointment for impending knee surgery.
Mr A told Hr Hill, "I was interviewed by a nurse on my particulars and health and in the process while looking through my records she stated that I had leukaemia. This came as a total shock to us both. We had never heard of this but she mentioned blood tests done [before I moved]... My understanding [was that] blood tests were done for blood pressure and cholesterol."
Expert adviser David Maplesden told Mr Hill that after receiving results indicating a diagnosis of CLL, he would expect any clinician to communicate to the patient, in a timely way, the results of that test and the implications of the conditon.
Mr Hill said, "I am concerned that although Dr C requested the blood tests and received the results, he did not ensure that Mr A was aware of the diagnosis."
He said doctors owed patients a duty of care in handling patient test results, including advising them of and following up on abnormal results.
He rejected a view of Dr C that he could have "deputised" someone else to do this. He also did not believe it was reasonable for Dr C to expect a public hospital would search a community laboratory database for such findings.
Mr Hill also asked the unnamed first medical centre to review its policy regarding high-priority test results and to audit compliance with its policy regarding the communication of test results to consumers.