Yvonne Maine was afraid of hospitals. She avoided going to the doctor and was petrified of surgery.
It was this fear that led the Feilding grandmother to natural therapy, and to Te Horo iridologist Ruth Nelson, who specialised in looking into people's eyes to assess their health.
After several years of treatment for various ailments, Mrs Maine revealed a lesion on her scalp that had been diagnosed by a GP as a harmless cyst nearly 40 years earlier.
Mrs Nelson was repulsed - it was "rotting and oozing pus" and had "eaten half [her] head off", she told the health and disability commissioner.
She admitted recognising that the lesion "looked cancerous" and that it was beyond her ability to treat, but she continued to do so anyway.
As the treatment progressed, the women became friendly and even went on holiday together. She did not tell Mrs Maine of her opinions about her condition.
Her treatments, which included washing out the lesion with colloidal silver and picking out dead skin with tweezers, increased to the point where they were spending several hours together every day, so Mrs Maine rented a house close to the clinic.
Initially the lesion appeared to improve, but it later doubled in size and frequently bled, and smelled unpleasant. Mrs Maine became weak and was in severe pain.
Family and friends urged her to see a doctor but she was scared of telling Mrs Nelson she had given up on her treatments.
A pharmacist questioned the amount of painkillers she was taking and suggested she see a doctor.
But she was warned against this by Mrs Nelson, who told her "it wasn't cancer and they probably wouldn't treat it now" and that she would "get a bug or swine flu" if she went to hospital.
By the time Mrs Maine sought conventional treatment 18 months later, the lesion had grown to 15cm by 20cm and had eaten through her scalp, exposing her brain.
The retired preschool teacher was found to have a carcinoma and had major surgery in 2009. But she died the following year.
Just before her death, Mrs Maine and her daughter laid a complaint with the health and disability commissioner, which was upheld in a written decision published yesterday.
Deputy commissioner Tania Thomas found Mrs Nelson had not kept written records of the care she gave, acted unethically by crossing professional boundaries and breached several rights under the Code of Health and Disability Services Consumers' Rights.
Renowned plastic surgeon Swee Tan, who operated on Mrs Maine at Hutt Hospital, said a big part of her scalp and skull had completely eroded down to the dura, which covers the brain.
"It was horrifying to see in this day and age to have such a large cancer essentially neglected," he told The Dominion Post.
"We were dismayed that she was not referred to any of us to deal with it much earlier on, because we would have been able to help her."
The operation restored her quality of life and enabled her to spend one last Christmas with her family, Prof Tan said.
New Zealand Medical Association chairman Paul Ockelford said Mrs Maine's death was "tragic and avoidable".
It highlighted the issue of whether natural therapists should be regulated. At present, anyone could say they were a naturopath.
Society of Naturopaths spokeswoman Jaine Kirtley said its 200 members were trained to refer clients to medical professionals when the need arose. Mrs Nelson was not a member of the society, which was self-regulated.
Mrs Nelson acknowledged that Mrs Maine needed to see a doctor, but said her philosophy was to put patients' wishes first.
"The mistake I made was not anything to do with the skills or knowledge, it was caring too much," she told the commission.
The commission's director of proceedings decided further action must be taken against Mrs Nelson.
Because she was not a registered medical practitioner she cannot go before the Health Practitioners Disciplinary Tribunal.
Instead, she will front up to the Human Rights Review Tribunal, which can impose damages, remedies and costs.
A date for the human rights hearing has not been set.
- The Dominion Post
Resource consent being denied for the Basin flyover is:Related story: Basin Reserve flyover bid turned down