A GP has been found in breach of the Code of Health and Disability Services Consumers’ Rights for failing to refer a woman for a termination of pregnancy in a timely manner, and his practice has been found in breach for long delays in handling her complaint.

In a decision released by Deputy Health and Disability Commissioner Vanessa Caldwell, the GP, Dr B, was found to have breached Right 4(1) of the Code after he did not refer Ms A for a termination of pregnancy (ToP) at the earliest opportunity and told her to wait until after the August 2021 COVID-19 lockdown to return for a second consultation.

Ms A first saw Dr B on 9 August 2021 at seven weeks and three days’ gestation. The consultation focused on pre-referral tests and anti-nausea medication. No referral was made that day. Dr B said he typically manages ToP requests in two consultations to discuss options and confirm a patient’s wishes, and the practice, Provider1, said this was its standard process.

Dr B acknowledged taking Ms A to the front desk and telling staff in English that she needed a “TOP workout” in a full waiting area, saying it was necessary to coordinate next steps. Ms A said discussing abortion services in the reception area caused her embarrassment and anxiety. The HDC was critical of this and said more private options were available.

On 18 August 2021, after investigation results were back, Dr B phoned Ms A — a call he did not document — and told her to return after the alert level 4 lockdown. He believed services were unavailable during level 4. The HDC said the private ToP provider (Provider2) remained open during level 4 and that a referral, or advising Ms A to self-refer, should have occurred once tests were organised or, at the latest, when results were back. The HDC also noted a virtual or phone consultation could have been used to avoid delay.

HDC clinical advisor Dr David Maplesden said HealthPathways guidance recommends immediate referral once tests are organised. He said advising Ms A to wait until after lockdown, when the duration was unknown and the matter was time-critical if she preferred a medical ToP, was inconsistent with accepted practice and would attract moderate disapproval.

Dr B told the HDC he “never had any intention of delaying her ToP services” and said he was unaware the private clinic was open during level 4, describing the period as “unprecedented and chaotic”. He said he considered a second consultation reasonable given Ms A’s limited English and the need to explain the private referral process. The HDC said not knowing the private clinic’s status was not reasonable and could have been resolved by a simple query.

Separately, Provider1 was found in breach of Right 10 of the Code for complaint handling. Ms A, with an advocate, attempted to raise concerns from September 2021. The HDC said Provider1 would not engage with the advocacy process despite multiple attempts, and did not provide a substantive response to the HDC’s initial information request until 19 June 2023 — around 18 months after the complaint was received. The practice then failed to respond to the HDC’s provisional decision despite several reminders in May, June and July 2025.

The HDC has recommended:

• Dr B and Provider1 each provide a written apology to Ms A within three weeks.
• Dr B complete training on privacy and managing ToP requests, and provide reflections and any practice changes within three months.
• Provider1 review its complaints process to align with the Code, provide the updated policy within three months, and audit compliance over six months, reporting outcomes within 12 months.

A copy of the anonymised report will be sent to the Medical Council and published on the HDC website for educational purposes.

In a statement to the HDC, Ms A said the experience was a “deeply painful and personal memory” and she hoped the findings would improve care for others.