A Palmerston North emergency department (ED) didn't meet the "expected standard" of care after a woman died from a heart attack not long after being discharged.
It comes after the woman, who was in her 50s, arrived at the ED with a history of chest pain that had been "coming and going" over a period of two days.
She was assessed and discharged after five hours before dying at home later that same day following a heart attack.
"While the ED specialist had identified that the woman should have been considered for admission, he did not take sufficient steps to ensure this happened," Deputy Health and Disability Commissioner Deborah James said.
"This case highlights the importance of clear and unambiguous communication between clinicians, as well as the critical importance of documenting such communication."
In a report released today, James found Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral (formerly the MidCentral District Health Board) breached the Code of Health and Disability Services Consumers' Rights over the incident.
She recommended the event be used to train staff on, "the importance of adequate documentation, effective communications, and referral processes for specialist services".
The HDC said MidCentral District has since approved and implemented an action plan to ensure learning from the incident was applied consistently across the organisation.
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