He died within days of his last visit as a result of a brain abscess, which is a rare but known complication of untreated otitis media.
The report described the deceased as a Māori man in his 30s who appeared to have had a history of drug addiction but was otherwise in reasonable health.
It said he had died due to a "wholly preventable condition" in spite of his multiple attempts to seek medical treatment.
At his first visit, he presented with an infection on his foot and an incidental discharge in his ear was noted.
He was discharged with antibiotics and a referral was made to WDHB's Ear, Nose and Throat (ENT) service – and later declined.
He returned a couple of weeks later suffering ear pain, neck swelling and a fever. Blood tests indicated a significant infection and so clinicians commenced antibiotics and a CT scan of his neck was undertaken.
The scan showed an infection of the external ear and fluid in the mastoid, part of the skull behind the ear. However, the middle ear and the roof of the mastoid could not be seen on the scan and no further imaging was performed.
The treating clinician felt the man needed to be admitted under the ENT specialist, referred to in the report as Dr G, for further review and antibiotic therapy.
But Dr G, who found a small growth in the man's ear, recommended he be discharged with eardrops, antibiotics, and an outpatient ENT appointment.
He described the man as "extremely active, getting up and sitting down repeatedly and pacing the hallway and euphoric/happy", he believed the man was experiencing acute methamphetamine intoxication.
The man's sister, who was with him at hospital and later made the complaint to the Health and Disability Commissioner about WDHB's services provided to her brother, said he was not intoxicated.
She felt Dr G had assumed that as the man was of Māori descent, he was a drug user, she told HDC.
Later in the day, following his discharge, a laboratory discovered in his samples a bacteria present that can cause acute life-threatening infections and "devastating" post-infectious after-effects.
WDHB was unable to reach him and as per its policy, the police were eventually enlisted to find him and relay a request for him to return to ED.
He did return, and at the visit his vital signs were normal, his neck swelling had reduced and there was no ear discharge.
It was the clinician's belief that the infection was resolving and so the man was discharged with a more intensive antibiotic treatment.
A couple of days later, he returned to ED with pain, pus in his ear and the eardrum was not able to be seen. He was later discharged by a junior doctor with more antibiotics and another ENT referral.
At the ENT appointment with Dr G the following month, the man arrived three hours early and was found sleeping in the waiting room.
He had to be woken and then fell asleep again during the examination. Dr G told HDC that he believed the man's behaviour was a result of substance abuse.
During the consult, the man's eardrum showed inflammation and discharge with a possible growth.
His vital observations were not recorded but a plan was made and it included the arrangement of a CT scan to view the temporal bone.
Within days, the man collapsed at home and was taken to ED by ambulance. His family reported he had been confused, disorientated and had been hallucinating.
CT imaging showed an abscess in the man's brain, arising from the bone behind his ear with fluid around the brain. He died three days later.
In her report, Caldwell found the DHB had failed to undertake a CT head scan earlier and had not followed up on abnormal test results adequately.
She was also critical of Dr G's inaction because of an assumption that the man's symptoms were a result of drug intoxication.
Caldwell noted DHBs are responsible for the services provided by their staff and said the clinicians involved in the man's care had neglected to appreciate the significance of his repeated visits to ED.
They had also failed to take into consideration his history of poorly resolving symptoms and the possible presence of complications, she said.
"Given the number of staff involved across multiple presentations, I consider that WDHB must take responsibility at an organisational level for the widespread failure in its service.
"These failures meant diagnosis of complications arising from the man's otitis media was delayed, and I therefore find WDHB in breach of the [Code of Health and Disability Services Consumers' Rights] for its failure to provide services to the man with reasonable care and skill."
Caldwell recommended WDHB and Dr G provide a written apology to the man's whānau.
She made multiple recommendations to WDHB, and further recommended Dr G undertake self-directed learning on bias in healthcare and reflect on his care in this case.
WDHB was referred to the Director of Proceedings and Caldwell stated that she "had regard to the particular vulnerabilities of the man and to the public interest in improving healthcare outcomes for Māori".
