By the time she had gastric bypass surgery her weight had increased by a further 20kg.
Her initial recovery was straightforward. She was reviewed by the surgeon six weeks after the operation and prescribed multivitamins to help overcome the risk of vitamin deficiencies faced by patients who have had gastric bypass surgery.
Over several subsequent weeks, the woman was admitted to a public hospital nine times with symptoms that invariably included abdominal pain, nausea, and vomiting.
The cause was not identified and the woman was not prescribed multivitamins by the hospital, the commission's finding said.
The surgeon was aware of the woman's admissions to the hospital and kept in contact with clinicians there.
On her 10th admission the woman complained of blurry vision. A neurology review indicated thiamine deficiency and a neurological disorder characterised by loss of muscle co-ordination that permanently harmed the woman's sight and mobility.
Her mother complained to the commission and during its investigation two independent experts raised concerns about the actions taken by the surgeon and health board.
Health and Disability Commissioner Anthony Hill found the surgeon breached the Code of Health and Disability Services Consumers' Rights by not adequately assessing the woman's suitability for surgery and failing to obtain a formal psychiatric or psychological assessment, or consult her psychiatrist.
He was criticised for failing to take steps to arrange for the woman to have an alternative way of getting multivitamins, and for failing to advise clinicians at the public hospital that he had prescribed them.
Mr Hill also found the Capital & Coast District Health Board breached the code after staff failed to ask whether the woman was taking multivitamins, or prescribe them until her thiamine deficiency was diagnosed.
In addition, staff failed to adequately assess the woman's nutritional status in light of her ongoing nausea and vomiting.
The doctor was ordered to apologise to the woman and review his practice around the assessment of patients before gastric bypass surgery.
He was also ordered to review his practice around the need to seek information from other clinicians regarding his patients' psychological suitability for surgery, and to review his reporting letters to ensure they contain all relevant information.
The health board apologised to the patient after receiving Mr Hill's provision finding and informed Mr Hill of efforts it had made to improve its internal processes.
