A 40-year-old woman's breast cancer diagnosis was delayed more than six months after her doctor failed to make a referral.
The doctor - who can't be named for legal reasons - has been told to write a formal letter of apology to the woman after being found in breach of the Code of Health and Disability Services Consumers' Rights.
HDC commissioner Anthony Hill found the GP in breach of failing to include relevant clinical information in a woman's referral for a routine breast screening mammogram and failing to refer the woman for diagnostic testing.
The woman presented to her doctor in May 2015 with right breast nipple discharge but the doctor did not document this.
As the patient was overdue for her yearly mammogram, the doctor sent an e-referral to the District Health Board (DHB) Breast Service for a routine screening, without any clinical background.