Ben Brown's father believes the 18-year-old's family have been denied justice over his death in Whangarei Hospital from meningococcal meningitis.
Darren Brown noted two inquiries for the Northland District Health Board had found bad decisions were made during his son's two spells in the hospital in August last year.
The doctors concerned had got off without any external disciplinary proceedings, he said.
"It's unbelievable the HDC [Health and Disability Commissioner's office] don't take them to task. The way the HDC have dealt with the hospital is all pretty soft really."
Commissioner Anthony Hill said in a letter to Darren Brown that he had decided not to formally investigate the case because the DHB had had it independently assessed, had accepted responsibility, apologised to the family, and adopted recommended corrective actions.
"It also intends to invite these advisers back to reassure the DHB, and you, that the actions it has taken are completed and will be effective in helping to prevent a recurrence," Mr Hill wrote.
Ben, a plumbing apprentice, was previously fit and healthy. He fell suddenly sick on a Wednesday evening after work. He had a painful neck, was noted by his girlfriend to be "sitting in a daze", was off his food and began to shiver uncontrollably.
He was taken to an accident and medical clinic, which sent Ben home with a meningitis leaflet and script for oral antibiotics for tonsillitis, and paracetamol. He deteriorated and went by ambulance to hospital, where he spent several hours before improving and being discharged. The oral antibiotics, although not sufficient to destroy the meningococcal bacteria, probably helped him feel better - and masked the real cause of his illness.
On the Thursday afternoon Ben suddenly worsened, was taken to a GP clinic, then hospital, now critically ill. He was given intravenous antibiotics, a CT scan, lumbar puncture test and was admitted to the intensive care unit (ICU).
Ben deteriorated. He died on the Saturday afternoon.
One of the independent reviewers, Dr Tim Parke, said that if Ben had had a lumbar puncture on his first hospital presentation, his chance of survival would probably have exceeded 90 per cent, although he had some misleading symptoms which made subsequently judging the decision not to do a lumbar puncture "very arbitrary".
Even at his second presentation, Ben had "a reasonable chance of survival".
Dr Parke noted a "major communication lapse" in an emergency doctor not giving written instructions to Ben's family, when he was discharged, to return there if problems developed.
The other reviewer, Dr Colin McArthur, also highlighted communication failures, including the written CT scan report findings suggestive of brain swelling and elevated intra-cranial pressure being overlooked for 36 hours.
The DHB said it had implemented virtually all of the reviewers' recommendations, including increasing the number of emergency department staff. But it has managed to recruit only one of the recommended preference for two intensive care specialists for the ICU, which is headed by a specialist who, although highly experienced in intensive care, is not vocationally registered as an intensivist.
Five years of hospital death rates have been made public for the first time - in the Herald. We compare health boards, investigate where lives are being lost and the battle to save them.
* Yesterday - District health boards compared, is death rate linked to healthcare quality, and how a simple check-list helps surgeons avoid mistakes.
* Today - Waitemata DHB boosts heart-care capacity. A bereaved father questions medical justice.
* Tomorrow - Waikato DHB strives to understand its high death rate, medication safety, and a doctor's apology.
* Thursday - Palliative care helps Auckland DHB's good performance. A widow fights for changes.
* Friday - Obesity skews the statistics in South Auckland. Lives saved by reduction of blood infections.Darren Brown says it's unbelievable the HDC's office didn't take Whangarei