Mr A spent one night in hospital, and was seen by several staff. However, only Dr B was found to have breached the code of health and disability services consumers' rights in her care of Mr A.
"Both of her clinical reviews of Mr A at 12.45am and 7am were poor, and did not fully take account of his history and clinical presentation," Mr Hill stated.
He also found the DHB, which had been notified of "serious concerns regarding Dr B's clinical competence and communication skills" and had failed to take adequate steps to improve the problems.
While the DHB had investigated problems with Dr B's treatment of patients, and issued her with a formal written warning, she seemed to have been unaware of its concerns, Mr Hill's report stated.
Problems with documentation of Mr A's case were also identified by Mr Hill.
The seriousness of Mr A's injuries and condition - which were missed by Dr B - was picked up at a medical centre eight days after he was discharged by the hospital.
Meanwhile, a Wairarapa rest home has been found in breach of professional standards after staff failed to provide reasonable care to an 89-year-old man.
The man had a complex medical history and required hospital-level care when admitted to Metilifecare Wairarapa Ltd rest home in late 2010, deputy health and disability commissioner Theo Baker said in her report.
The man's fluid and food intake and his weight loss was not adequately monitored. There was also no plan in place to mitigate the risk of him falling, despite several incidents, and his injuries also went undocumented, the HDC said.
In one incident, a registered nurse tried to feed the man - whose name has been suppressed - while he was unresponsive and had low blood pressure. The man choked as a result.
Ms Baker said poor clinical oversight and problems with staff, including poor direction and confusion contributed to widespread failures in the man's care.
He died eight months after being admitted to the rest home.
