A person became pregnant and was traumatised after a sexual health clinic failed to re-insert their contraceptive device.
The person had a fear of becoming pregnant and had been diligent about contraception.
The clinic and the doctor involved have been criticised in a Health and Disability Commissioner's (HDC) report, released on Monday.
The person, who identifies as non-binary and was referred to in the report as Mx A, went to have their old Jadelle contraceptive removed from their arm and another one replaced in 2021.
But the doctor did not insert the new one, the report said.
A few months later, while overseas, the patient became pregnant.
"Mx A stated that this was a 'huge shock', and the termination was an 'extremely traumatic experience'," the report said.
They had to take significant time off work to process the emotional trauma, and for medical appointments.
That included x-rays and ultrasounds to try to locate the implant.
When the device was never found, a review of notes from the original appointment read that Mx A had declined to have a new contraceptive device inserted when the old one was removed.
But Mx A told the Commissioner it was "utterly absurd" to suggest they would refuse one - and they had been very clear about wanting a replacement.
"Mx A told HDC that pregnancy is a 'major fear' for them, and, as a result, several proactive steps were taken (including telephoning the clinic months prior to check when their implant was due to expire and booking an appointment in advance to ensure that there were no lapses in contraception)," the report said.
Deputy Commissioner Vanessa Caldwell said the doctor had made significant errors which had significant adverse consequences for Mx A.
"I consider Dr B's failure to replace Mx A's Jadelle implant to be particularly concerning given Dr B's specialised qualifications in this area and experience working at the clinic, which included 'special training for implant insertions'," she said.
But she commended the GP for making several changes since the event, including attending training on informed consent.
"I encourage Dr B to continue to develop competency in effective communication, as it is a critical component in ensuring that people of all orientation and gender identities receive acceptable and appropriate health services," Caldwell said.
The clinic itself told the Commissioner it could not apologise enough for the trauma caused by the incident.
It had a "toolkit" about discussing contraception options and risk factors with trans and gender-diverse consumers.
The Deputy Commissioner thanked Mx for making the complaint.
"I acknowledge the ongoing traumatic effect of this event on Mx A and their desire to prevent this from occurring to others in the future," she said.
