A 20-year-old woman died of a cardiac arrest caused by blood poisoning after Auckland District Health Board repeatedly failed to document her treatment and tests.
The Health and Disability Commissioner has found the DHB in breach for failing to provide a high standard of care.
The woman - who has not been named for personal reasons - was admitted to Auckland City Hospital for follow up tests and treatment after undergoing surgery to insert a pacemaker a month earlier. The dates have not been disclosed by the HDC due to privacy.
During her time at hospital she had complained of a sore arm, saying she was unable to bend it.
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A nurse removed the bandage from her arm, where a peripheral intravenous catheter (PIVC) had been inserted to draw blood, and found spots but insisted it was fine, Health and Disability Commissioner Anthony Hill found.
Throughout the woman's stay, staff repeatedly failed to document observations of her PIVC site, including the swab test which was done as a precautionary measure after it was removed.
The woman was discharged from hospital with no documentation.
In the report, the doctor who discharged the woman said because of the urgency for the patient and her mother to get to the airport he was unable to complete the discharge summary before they left. Instead, he agreed to prepare the discharge summary later that day and email it to them.
Two days later, the woman presented to her GP who immediately called an ambulance to hospital, where she was diagnosed with septicaemia, also known as blood poisoning.
The next day the woman died from a cardiac arrest caused by septicaemia.
In the report the woman's mother said she believed her daughter would still be alive had certain events not taken place.
"I believe these small details were either omitted, ignored or not taken seriously. She had prior medical records of skin infections, she had surgery, she was implanted with a pacemaker, the swab was never taken seriously."
Hill has recommended Auckland DHB write an apology to the woman's family within three weeks of this report.
It also advised the introduction of new policies relating to its electronic discharge summary and insertion of PIVCs into patients. The DHB were also told to conduct a review of the effectiveness of these new policies and report back to HDC.
Hill also instructed that this report be used as a basis for training staff at Auckland DHB.
In response to the commissioner's investigation, Auckland DHB told HDC it had undertaken its recommendations.
Auckland DHB's chief medical officer Margaret Wilsher said in the report: "On behalf of Auckland DHB, I would like to say how sorry I am for the tragic outcome of [Ms A's] care. I hope that we can continue to build on what we have done already to improve the care we provide to others to reduce the chance of a similar event occurring in future."