A young child who died after being sent home from an emergency department with a fever was let down by hospital staff, the health watchdog says.
A report from Health and Disability Commissioner Anthony Hill has criticised doctors and the Southern District Health Board over the two-year-old girl's death in 2013.
The commissioner heard the girl had been taken to hospital after her cough and runny nose turned into a fever, and was treated and discharged.
But when she got worse over the next two days, her mother took her back to an emergency department, only to be sent away after an hour.
"The house officer did not document any discharge information provided to the girl's parents, and he did not request a follow-up telephone call from the paediatric department," the report said.
The next morning, the girl had a temperature of 40.2degC and the mother called a telehealth services, only to hang up about three minutes into the call.
The call was never returned and the child stopped breathing later that day, with an ambulance unable to revive her.
The cause of death later found to be pressure on the brain from pneumonia.
Mr Hill found DHB staff had ignored the red flags about the child's condition.
"By approving the girl's discharge home following her second presentation to ED without first taking sufficient steps to investigate the cause of her presenting symptoms, the consultant failed to provide the girl with services with appropriate care and skill," he said.
He also criticised the telehealth service for not properly triaging the child and not calling back to check if the child would be brought to a hospital.
He made a series of recommendations aimed at improving the DHB's policies about patients under five, safe staffing levels, training and also suggested a review of telehealth service policies.
A consultant, a house officer, the DHB and the telehealth nurse were all asked to make written apologies to the girl's parents.