The woman underwent surgery in February 2019 and understood she was to have her left ovary and left-fallopian tube removed, but had given written consent for that.
The surgeon, referred to in the report as Dr A, said he discussed removal of the right fallopian tube (known as a salpingectomy) with the woman, B, due to the risk of future cancer.
He said he did this just prior to the surgery.
While the removal of both fallopian tubes was noted in the woman's discharge summary, the woman said she was only made aware of the removal of the right tube when she was advised by an ultrasound technician a year later.
She said she had asked the technician during a scan about the impact on fertility of having only one ovary, and the technician had advised her that it appeared that she had only one ovary and no fallopian tubes.
Ms B's GP later confirmed with her that both fallopian tubes and the left ovary had been removed during the February 2019 surgery.
In her report, Deputy Health and Disability Commissioner Dr Vanessa Caldwell was critical of the doctor for advising the woman of the change in surgical plans - to include the right salpingectomy - in the preoperative holding bay while the woman was showing signs of acute stress relating to the procedure.
"The environment in which this option was put to her was inappropriate. It affected her understanding of her surgery and the effect the procedure would have on her fertility was profound".
Caldwell said the risks, benefits, and options were not explained to her appropriately, particularly its potential effects on her fertility.
She was also critical that the written consent form did not include the right salpingectomy, because following the change in the surgical plan the doctor did not update the written consent form.
Caldwell also made adverse comment against Te Whatu Ora/Health NZ for systemic issues relating to informed consent practice because, in the woman's case, a surgical safety checklist was not followed.
A range of recommendations were made, including that the doctor provide a formal apology to the woman and completes the HDC's online learning modules about the code. Caldwell also recommended Health NZ perform an audit of the last 30 clinical records for compliance with its informed consent policy.
