The woman had a mastectomy for invasive breast cancer in 2002, and was admitted to hospital five years later with sudden, severe back pain.
Doctors put it down to muscle spasms and didn’t order an MRI or bone scan, despite the woman’s request.
Seven months later, an MRI confirmed she had bone cancer in her spine and pelvis.
The woman died last year.
In his report, Heath and Disability Commissioner Anthony Hill says opportunities were missed, when questions should’ve been asked.
He says the doctors made assumptions, including that the hospital’s cancer experts would check for cancer later.