A woman who was discharged by the Capital and Coast District Health Board (DHB) despite having collapsed multiple times as well as suffering other symptoms, was later found to have a brain tumour.
The woman went to the DHB's emergency department (ED) after she collapsed. She also had pain in her neck and was vomiting.
However, a statement released on Monday by Health and Disability Commissioner Anthony Hill says the woman was not offered a CT scan or referred for an urgent neurology review, instead she was discharged with advice to see her GP if she "started to feel worse".
She continued to experience the same symptoms and following a seizure and loss of consciousness about two months later, she went to the ED again.
However, no neurological assessment was carried out.
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An initial referral to the general medicine team was declined, but when a second was accepted, she was found to have a brain tumour.
Hill was critical that the woman was not offered an adequate neurological review, and that her first referral was declined without assessment.
The findings prompted an apology from the DHB. Chief medical officer Dr James Entwisle said no injury, or misdiagnosis, under a patient of their care was acceptable.
The DHB had undertaken a thorough review to look at "what lessons could be learned, and what changes could be made," he said in a statement to Newshub.
"We take patient safety extremely seriously, and acknowledge that we failed the patient and family in this instance.
"We also accept the Health & Disability Commissioner's finding that we did not provide services of reasonable care and skill."
Hill recommended the DHB consider a number of changes relating to the "overview of consultants of junior doctors' cases", and "consultant involvement in cases where patients re-present to ED", or where they wish to leave the hospital against medical advice.
He also recommended changes relating to documentation and criteria for urgent CT head scans.