The Canterbury District Health Board (CDHB) has come in for criticism over the way it handled the care of a 3-year old boy who died.
Deputy Health and Disability commissioner Rose Wall found there were multiple failures in his care.
She said the CDHB was in breach of the Code of Health and Disability Services Consumers' Rights.
The boy became unwell and was seen twice at a medical centre, then transferred to an urgent care clinic before going to the public hospital.
He was admitted to the children's ward, but some of his vital signs were not observed regularly or recorded, resulting in an early warning scoring system identifying at risk patients, being inaccurate.
After being stable overnight his condition deteriorated rapidly the next morning.
He died from bilateral pneumococcal pneumonia and tests indicated he had developed sepsis, a life-threatening whole-of-body response to infection.
Wall said staff failed to think critically about the boy's overall clinical picture, and as a result failed to escalate his care and explore the possibility of sepsis more thoroughly.
She recommended that the CDHB:
provide training to paediatric nursing and medical staff on the recognition of a deteriorating child, based on the clinical picture and on critical thinking and challenging assumptions
consider whether a review of its health pathway for administering oxygen therapy could be warranted
provide a written apology to the boy's parents.
Wall also wanted the DHB to provide evidence that all the recommendations from its Serious Event Review have been implemented and their impact evaluated.
She said it was impossible to know whether the outcome would have been different if the errors had not occurred.
''However, I consider that the failures resulted in a lack of recognition and response to the boy's serious illness and the emerging signs of his deterioration.''
Wall also recommended that the medical centre provide training to clinical staff on the recognition and treatment of sepsis in children, and offer a written apology to the boy's parents.