A woman in her 40s died after being rushed into an emergency room with severe chest pain, and an investigation into her care aims to save others from similar heartbreak.
She died of an aortic dissection - it's a life-threatening condition resulting from a tear in the lining of the aorta, which is the largest vessel that carries oxygenated bloody from your heart to the rest of your body.
Earlier this year, former Black Cap great Chris Cairns was left paralysed after the potentially lethal condition.
After the woman's death, her family complained to New Zealand's health watchdog known as the Health and Disability Commission (HDC) because they believed the tragedy could have been avoided. The agency agreed to investigate.
A HDC report, released today, found no breach to consumer rights but listed recommendations to prevent the tragedy being repeated. This included using this death as an educational tool for doctors and better developing diagnostic testing.
The report also included an apology from one of the doctors to the woman's family: "I would like to offer my condolences to [Ms A's] family, particularly her daughters, for their very sad loss.
"I am deeply appreciative of the thorough review of this case and have reflected on the feedback provided. I am sincerely regretful of the outcome. When I heard the news of [Ms A's] death, I was devastated."
The woman, her family, doctors and District Health Board are not named in the report for privacy reasons.
Health and Disability Commissioner Morag McDowell said in the report, that the appropriate standard of care was provided by the DHB and it was clear the condition was difficult to pick up without "failsafe diagnostic tools".
"As a healthcare provider, the DHB is responsible for providing services in accordance with
the Code. In this case, no broader system issues at the DHB were identified," McDowell said.
She said: "I hope that the recommendations made will aid in minimising such outcomes for other patients and their whānau."
Half of the people who develop the condition die before they get to hospital. Of those who make it to hospital, another 50 per cent don't survive.
Last month, the Herald reported on world-first research aiming hoping to save the lives of dozens dying each year of aortic dissection.
A Waikato heart surgeon, an aortic dissection survivor and a University of Auckland researcher facilitator have joined forces to investigate hypertension (high blood pressure) in patients and how to best manage it. High blood pressure is seen as a common trigger for aortic dissection.
They also plan to set up an aortic dissection registry to help understand the prevalence of the condition in New Zealand better.