Junior hospital doctors say they are being left on their own at night to manage risky patients because of workforce shortages.
A report by Health and Disability Commissioner Ron Paterson has faulted an inexperienced British-trained doctor and his employer over the death of a child in hospital in 2007 after an asthma attack.
But Deborah Powell of the Resident Doctors Association says less experienced doctors should gain the necessary experience before being put on duty alone at night.
She says doctors may be reluctant to seek advice in the middle of the night, but the issue is bigger than that. As well, district health boards should do more to protect patients and staff.
Mr Paterson says the junior doctor did not realise the severity of the attack or called for help and Bay of Plenty District Health Board must share the blame.
The child, aged two and a half, was admitted to Tauranga Hospital with moderately severe asthma, but deteriorated. The child suffered a respiratory arrest and died four days later of severe brain damage.
Mr Paterson says the doctor was on only his seventh night as the sole doctor on duty in paediatrics and did not realise the gravity of the situation.
He says the doctor should have phoned the on-call paediatrician and listened to the child's mother, who was insisting that the specialist be called.
Mr Paterson also says the district health board did not do all it could to prevent the shortcomings.
Whangarei paediatrician Roger Tuck, who carried out a review of the incident for the district health board, says the death was preventable.