A doctor in New Zealand who did not take the temperature of a woman who died a day later has been found to have failed to recognise the seriousness of her symptoms and to take appropriate action in response.
The doctor was found to be in breach of the Code of Health and Disability Services and Consumers' Rights, a report has revealed.
Deputy Health and Disability Commissioner Kevin Allan released a report on the findings on Monday.
The 42-year-old woman came to a medical centre and reported being ill for three days, with difficulty breathing and difficulty sleeping.
She was seen by a doctor who requested a practice nurse carry out an electrocardiogram (ECG).
The doctor did not take the woman's temperature.
The ECG showed an abnormally rapid heartbeat, sinus tachycardia.
The doctor also observed the woman had a cool periphery and hypotension.
The doctor considered the most likely cause of the sinus tachycardia was alcohol abuse and anxiety and prescribed medication to slow down the woman's heart rate.
The doctor told the woman to return if her symptoms did not improve within two days
At the end of the day the nurse was "very surprised" to see the doctor's note and course of action, the report read.
The nurse arrived at work the next day and discussed her concerns with the Clinical Nurse Leader.
The leader advised the nurse to follow up on the woman to see how she was feeling.
At 4pm, the day after the woman came in, the medical centre received a call from paramedics at the woman's house, saying she had been found deceased.
An expert, Doctor David Maplesden, who advised on the case, said it was "mildly to moderately critical" the doctor did not take the patient's temperature.
Maplesden said it was neither a safe nor reasonable action to attribute the findings observed to "anxiety and alcohol" and to treat the tachycardia with a beta-blocker without further investigating the cause.
The doctor was referred to the Director of Proceedings and the medical centre was not found in breach of the Code.
The Deputy Commissioner recommended the doctor provide a formal written apology to the woman's family, and the Medical Council of New Zealand consider carrying out a competence review should the doctor reapply for a practising certificate.