A man was fully circumcised despite telling both a consultant urologist and operating theatre staff that he did not want to be.

The Health and Disability Commissioner found Health New Zealand breached the Code of Health and Disability Services Consumers' Rights after the man was circumcised without his consent.

He was seen by a consultant urologist, via a telehealth appointment, due to balanitis xerotica obliterans (BXO), a thin, white, scaly and inflammatory patch that appears on the foreskin of the penis.

While explaining the surgical procedure needed to treat the condition, the consultant told the man there was a chance that a full or partial circumcision may be required.

The man told the doctor he did not want a "full" circumcision.

The man was not provided with written information about the procedure, nor was he provided with a copy of the consultation documentation, said Deputy Health and Disability Commissioner Dr Vanessa Caldwell.

On the day of the surgery, the man met with the operating surgeon who was a different person from the consultant urologist.

The surgeon said the usual treatment for BXO was a circumcision so proceeded on that basis, noting that on the consent form having discussed the procedure with the man prior.

The man said he was confused by the terminology used but continued to sign the consent form because he assumed the cutting or removal of the scar tissue on the frenulum was a form of partial circumcision, not knowing that he was consenting to a full circumcision.

While he was in the operating theatre he reiterated to other clinical staff (not the operating surgeon) that he did not want a full circumcision.

However, no one raised concerns to the operating surgeon and a full circumcision was completed.

Caldwell's report found that the man's understanding of the procedure was different from what was listed on the consent form and departed from the expected standard of care.

She found the man was not provided with adequate information prior to his surgery; in particular, there was a lack of clarity about the extent of the procedure, he was not provided with written information, and he was not advised that a different person may be operating on him at the initial consultation.

Caldwell also found that consenting took place in an inappropriate place, and there was a lack of mutual understanding amongst the providers, resulting from ineffective communication processes, which contributed to the man's unexpected surgical outcome.

Since the events, Health NZ has made a number of changes, including that the theatre operational leadership team would continue regular audits of consent forms of patients presenting for elective surgery.

Caldwell recommended Health NZ to provide a formal written apology to the man, provide an update to HDC on its implementation of a new system that supports sharing of clinical appointment letters with its patients, and remind staff that patients should be given adequate time and opportunities to ask questions about the proposed surgery.

-RNZ.