A dermatologist failed to test a woman to see if she was pregnant, before prescribing her a drug which was harmful to an unborn child.
A report, released on Monday, found the dermatologist in breach of the code of health and disability services consumers' rights.
A young woman with a history of severe acne went to a dermatologist, and was prescribed isotretinoin, says the report.
At the consultation, the dermatologist knew that there was the possibility that she was able to have a child, despite the woman not saying anything to indicate she may be pregnant.
The dermatologist prescribed the woman isotretinoin, but excluded a pregnancy test when ordering pre-treatment monitoring blood tests.
By prescribing the woman isotretinoin without a pregnancy test, the dermatologist failed to provide services to the woman with reasonable care and skill, says Health and Disability commissioner Anthony Hill.
The dermatologist provided a written apology to the woman and arranged to enrol in a communication skills course.
No further recommendations were made.