A man who saw his GP five times for a worsening cough died of respiratory failure the day after the fifth appointment.
The GP has been found by Health and Disability Commissioner Anthony Hill, in a report made public today, to have breached the code of patients' rights.
The man - no party is named in the report - consulted the GP after he began to have coughing fits, particularly at night. Antibiotics were prescribed.
Several months later the man returned due to further coughing fits, bleeding from the nose, and episodes of shortness of breath. The GP sent a semi-urgent referral to the local district health board's specialist respiratory service.
Some days later, the man experienced a night of continual coughing for about eight hours.
The GP documented that the man needed an urgent respiratory appointment.
He told Hill's investigation he sent a referral to the DHB for urgent specialist assistance.
Hill said there was no evidence of a referral in the medical notes and the DHB did not receive any such referral.
The man returned to the GP a week later. The GP sent a new referral to the DHB, this time for specialist gastroenterology review.
The DHB later informed the GP an appointment had been made for the man at "the medical clinic" in about six weeks.
The GP assumed this booking was for the specialist respiratory service. In fact, it was for the gastroenterology review.
The DHB later informed the man he had been booked for respiratory testing in about three weeks. However, the DHB did not inform the GP about the respiratory testing.
This visit occurred a week after number four. The GP was fully booked with other patients, so did not review the man formally or examine him physically. However, he did see the man and prescribed an antibiotic.
The next day, the man died. His post-mortem recorded his cause of death as "respiratory failure due to severe pulmonary oedema and pleural effusions".
Hill found several weaknesses in the GP's care of the man.
He failed to advocate appropriately for the man. In particular, the GP did not follow up the respiratory referral or inform the DHB when the man's condition deteriorated. The GP seemed unaware that he was best placed to attempt to bring forward the specialist appointments.
The GP omitted to carry out appropriate physical assessments before prescribing an antibiotic.
His clinical notes did not contain sufficient information about what had occurred during the man's appointments.
Hill made "adverse comment" about the DHB over its communication with the GP.
The DHB did not specify that the first appointment booked for the man was a gastroenterology review, and failed to inform the GP when the man was scheduled for respiratory testing.
"Providers must maintain clear lines of communication so that misunderstandings and incorrect assumptions are minimised. Co-operation and communication between providers involved in delivering co-ordinated health services are vital to ensure quality care."
Hill told the GP to do more training on clinical documentation, and report back on the effectiveness of changes he had made to his practice following this case.
He told the DHB to report back on changes made to its communication systems.