A natural health practitioner treated a woman with a lesion on her head for 18 months, even though the practitioner recognised from the beginning that the lesion "looked cancerous".
By the time the woman sought hospital treatment, the lesion was 10 x 11cm and some underlying bones were damaged, the Health & Disability Commissioner (HDC) said.
The woman was diagnosed with cancer and underwent major surgery but died a year later.
She had first consulted the iridologist and natural health practitioner about the lesion in February 2008. At the time the woman thought the lesion was a cyst.
Iridology is the diagnosis of a patient's health by looking at their irises.
The provider recognised from the beginning that the lesion "looked cancerous" and that it was beyond her ability to treat, the HDC said.
Despite that, the provider treated the lesion for 18 months.
"To do so, the provider spent many hours each day at the woman's house and the woman and provider went on holiday together."
Treatment of the lesion included picking out dead skin, cleaning the lesion, and the use of topical and oral remedies.
Although initially the lesion appeared to improve, it later grew larger, was frequently infected, bled frequently, and smelled unpleasant. The woman became weak and was in severe pain, the report said.
The provider did not retain any records of the care she provided and no other health practitioner treated the woman's lesion during that time.
Despite being aware the lesion was likely to be cancerous, the provider did not inform the woman of her opinions about the severity of the woman's condition or that the lesion was worsening during the course of the treatment, the HDC said.
The provider knew that she had exceeded the limits of her expertise and that the woman needed advice from another practitioner, but she did not appropriately communicate that or discontinue her treatment of the woman, and she gave the woman information which accentuated the woman's fear of conventional treatment.
The provider also acted unethically by crossing professional boundaries in her close relationship with the woman.
The provider was found to have breached rights under the Code of Health and Disability Services Consumers' Rights.
She was referred to the director of proceedings to decide whether any action should be taken.