A man who received a bone graft did not realise until four months later it had come from a deceased donor, a Health and Disability Commission report says.

He was upset, saying it was against his cultural and religious beliefs.

Deputy Health and Disability Commissioner Vanessa Caldwell said his doctor failed to inform him who and where the tissue was coming from and therefore breached his right to give informed consent.

The man, who is Māori and known as Mr A in the report, had surgery on his wrist in July 2015.

Bone tissue was transplanted, but he did not find out until a post-surgery review in November that it had come from a deceased donor.

"Mr A told [the doctor] he was upset about this as it was against his cultural and religious beliefs and that he wished he had been told about this before surgery," the report said.

The doctor could not remember the exact conversation he had with the man beforehand, but acknowledged it was clear he had not properly explained the process, the report said.

He told the commission it had been difficult to communicate with Mr A at times because of his distress, trauma and chronic pain, so standard "fulsome discussion" on the procedure did not happen.

He said he had not been aware of the man's ethnicity.

The report said the consent form the patient signed did not say the donor tissue would come from another person and there were no records of it being explained.

Caldwell said even if there were challenges with communication, it was the doctor's responsibility to make sure their patient had the information they needed.

If that could not be achieved, consideration should be given to not proceeding, she said.

The doctor had offered an apology.

He told the commission he had changed the way he worked to make sure he was aware of his patients' cultural and religious beliefs and made sure he was clear with them about where donor material comes from.

Culturally safe care was fundamental, the report said.

"The use of donor material does have significant implications for people of different ethnicities, cultures and faiths and it is important to acknowledge the cultural implications the inadequate information had on Mr A as a Māori man," Caldwell said.

"Adequate disclosure of the the allograft process, specifically that bone tissue was to be received from a deceased person would have ensured sufficient time to undertake cultural processes which would make this an acceptable procedure to undergo and that the correct tikanga and kawa were engaged."

Caldwell would work with Health NZ as it developed a national policy on informed consent for bone grafts.

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