A woman died at Taranaki Base Hospital in 2019 after staff initially failed to recognise her condition.
Details of the incident were revealed in a finding by the office of the Health and Disability Commissioner (HDC), released today.
The woman was admitted to the hospital's emergency department by her GP, feeling unwell after a recent cancer treatment overseas.
"The medical team in the ED did not recognise that the woman was seriously ill, and her acute condition was not identified until she was on a medical ward 12 hours after admission," a statement from the HDC said.
"The woman was transferred to the High Dependency Unit, however, her condition rapidly deteriorated and she passed away."
She had sepsis, a life-threatening condition caused by the body's extreme overreaction to an infection.
Deputy Health and Disability Commissioner Vanessa Caldwell found "systemic and organisational issues" led to the delay.
She found Te Whatu Ora Taranaki (previously Taranaki DHB) in breach of the Code of Health and Disability Services Consumers' Rights.
"The errors and omissions that occurred during the time the woman was at Taranaki Base Hospital were, in the main, not the result of isolated incidents involving individual staff members," Caldwell said.
"Rather, many staff missed opportunities to recognise and respond to the woman's serious illness."
The findings also note that no senior doctors were "meaningfully" involved in her care in the first 13 hours of her admission.
Caldwell expressed her sympathy to the woman's family.
"Although the woman was living with metastatic cancer, she believed that chemotherapy could contain it and potentially allow her to live for another nine months to three years," she said.
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