The Bay of Plenty District Health Board has been told to apologise to the family of a man in his nineties who sought treatment for severe abdominal pain at hospital and died two days later.
The Health and Disability Commissioner found the DHB failed to properly care for the man.
A report led by Health and Disability Commissioner Anthony Hill ruled there were "a number of deficiencies" in the care of the man which was found to breach the Code of Health and Disability Services Consumers' Rights, a statement from the Commissioner reads.
The man in his nineties had been brought into a emergency department one afternoon with signs of severe abdominal pain but was released later that day after being treated for gastritis.
His condition worsened overnight and led to him being rushed back to hospital the following morning, he was diagnosed with having reduced blood flow to his large intestine as well as a blockage in one of his main arteries which supplied blood to the intestines.
By this point, nothing was able to be done for the man who died two days later, the statement reads.
While acknowledging the emergency department was busy at the time when the man was first admitted, Commissioner Anthony Hill says his initial assessment was not adequate and led to him being "discharged inappropriately."
"...opportunities were lost to identify and respond to his condition appropriately".
The investigation found there was significant delays in the emergency department when it came to the man's treatment which included a delay of five hours for his vital signs to be taken.
Delays in the man being assessed in the emergency department, the lack of supervision of a junior doctor as well as not being seen at all by a senior doctor combined with the initial misdiagnosis were found to have led to the code breach.
The errors by the Bay of Plenty DHB indicated a broader issue with systems and resources for the health board according to Mr Hill.
Recommendations by the Health and Disability Commission include recommending the DHB write an apology to the patient's family, as well as update their Acute Abdominal Pathway document and provide training for junior emergency department doctors when it comes to using clinical documents.
The Bay of Plenty DHB has also been recommended to conduct an audit of wait times in the emergency departments over the past three months.
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