A doctor who did not diagnose meningitis in a toddler who died soon after had not made a diagnostic error, an investigation has found.

Te Tai Tokerau primary health authority and the Northland District Health Board had conducted a sentinel event investigation into whether an on-call doctor at Bay of Islands Hospital made mistakes in diagnosing and treating the 14-month-old child on October 14.

The investigation found that any doctor would have had difficulty identifying that the child had meningitis.

However, the Kerikeri doctor could have made it clearer to the father of the 14-month-old - who had been treated for gastroenteritis and an ear infection - what he should do if the child's condition worsened.

Northland PHOs will now issue a wallet-sized card for parents to use as a prompt when seeking medical advice for their children.

The sentinel event investigation has also led to Northland PHOs offering on-going professional development for all general practitioners which would include improved documentation, follow-up planning and management in the after-hours setting.

Northland Primary Healthcare clinical director Kyle Eggleton, who led the investigation, said meningococcal disease was unpredictable, moved rapidly and its presentation was variable.

His inquiry found the after-hours duty doctor did not make mistakes in his initial treatment for gastroenteritis and an ear infection.

The child was discharged but died at home a few hours later.

"There is no real criticism of the doctor's treatment of the case," Dr Eggleton said.

Another doctor might also have missed the likelihood the illness could lead to strain-B bacterial meningococcal disease and, subsequently, death, he said.

"Making the correct diagnosis of meningococcal septicaemia is difficult especially in early presentations."

However, after meeting with the child's parents on October 25, Dr Eggleton came to the conclusion the GP had not ensured the child's father fully understood the advice given or the observation instructions.

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