A man suffering coughing fits and bleeding died after his doctor failed to get him to specialist care fast enough, the health commissioner has found.
Health and Disability commissioner Anthony Hill on Monday released a report finding the general practitioner breached New Zealand's medical code because he failed in his services to his 38-year-old patient during a series of consultations in 2013.
Mr Hill said the patient repeatedly visited the GP because he was experiencing nights of coughing, bleeding from the nose and episodes of shortness of breath.
The GP initially prescribed antibiotics before later issuing a referral to the local district health board's specialist service.
However, Mr Hill said when the patient returned several days later, there was no evidence in his medical notes of the referral.
When the GP this time issued an urgent referral, he was informed by the district health board his patient had been booked in for a gastroenterology review. The GP assumed this appointment was to meet a respiratory specialist.
A week later, before the patient met the respiratory specialist, he revisited the GP, who was fully booked and did not review the man formally or physically examine him but did prescribe an antibiotic.
The man died the next day from respiratory failure.
Mr Hill criticised the GP for failing to warn the district health board his patient's condition had deteriorated and for failing to act to ensure his patient met a specialist at an earlier date.
He further criticised the GP's clinical note-taking, which did not contain enough information, and said the district health board could also have communicated with the doctor better.
Mr Hill recommended the doctor undertake further training on how to improve his clinical documentation and report back to the commission.