Individual clinicians aren't being blamed for not immediately diagnosing Wellington toddler William Burton with meningitis, the blame being placed on a lack of "senior clinical engagement", a report says.
A doctor involved in William's treatment has also apologised, saying she has been "deeply affected" by the outcome of the case.
Doctors twice missed the symptoms of the disease in the two-year-old, who was left severely brain damaged, a quadriplegic and unable to speak or see.
A report into the case by the Health and Disability Commissioner released this afternoon says a review team which looked into what happened concluded that senior staff not being engaged in the process meant early diagnosis and treatment was missed.
"The review team do not consider individual clinicians directly responsible for the lack of more senior clinical engagement.
"Rather the review team consider the main contributing factor to this incident is a lack of formal processes regarding more senior paediatric medical staff oversight of the paediatric junior medical staff clinical assessments and discharge planning."
As part of the review, "incidental findings" were incorrectly recorded on some relevant clinical documentation.
William was first taken to Wellington Hospital on the night of October 16, 2013 and again the following day.
In the second incident, the review team says the opportunity was missed for further investigation and intervention, given William had had an elevated temperature for more than 48 hours and appeared unwell.
The Capital and Coast District Health Board provided a statement from the doctor who was involved in treating William passing on their apology and regret.
"It is difficult to convey in writing the distress and regret felt after hearing of William's neurological injury. I have been deeply affected by the outcome of William's health and cannot begin to imagine how affected the Burton family must be.
"I wish to pass onto the Burton family my sincere and unreserved apology as I remain saddened by the permanent disability William has sustained."
The doctor's name has been redacted from the report and has since moved overseas.
The DHB has also apologised, saying the boy's care was "not of the standard we expect to provide children and their families requiring our child health service".
It says it fully accepts the commissioner's findings and a formal assessment and discharge process for patients seen by junior doctors has been developed for "greater clinical oversight" from senior doctors.
Any child who re-presents at hospital within 72 hours will now be assessed by a senior doctor before being discharged.
A paediatric registrar, a doctor with at least three years' experience, will also now be on duty at all times.
The DHB has also issued a written a formal apology to the family.
The Commissioner recommended the report be used for staff training at Wellington Hospital.
Health and Disability Commissioner report into William Burton
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