A general practitioner may face legal action after the Health and Disability Commissioner found their mistakes contributed to the death of a 57-year-old woman with a history of breast cancer.
The unnamed doctor failed to warn the patient she had cancer in a shoulder, telling her only that she had a torn tendon.
The GP has been referred to the director of proceedings, who is considering whether to lay charges.
Commissioner Anthony Hill outlined several breaches of the Code of Health and Disability Services in his report into the case.
The general practitioner did not tell the woman, who had complained of pain in her left shoulder, about cancerous lesions picked up by an X-ray and ultrasound.
The doctor referred her to an orthopaedic surgeon with a note that failed to mention the lesions and touched only briefly on the woman's history of cancer.
The orthopaedic surgeon diagnosed the woman with a cancerous lesion in a shoulder. She died after a period of treatment.
Hill found the GP failed to arrange a timely follow-up after receiving an imaging report for the X-ray and ultrasound.
The GP also failed to discuss the X-ray and ultrasound results with the patient and did not give the orthopaedic surgeon adequate information.
Hill recommended the GP apologise to the woman's family, review their practice and conduct an audit to make sure patient test results received over the last two years were revisited.
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