The Health and Disability Commissioner has criticised the West Coast District Health Board for not providing urgent medical treatment for a patient who now suffers from brain damage.
In a report, the commissioner recommends that the DHB review its induction process for locum doctors and criticises poor clinical documentation.
In September last year, a 54-year-old patient admitted to Grey Base Hospital in Greymouth suffered a ruptured brain abscess after not getting urgent attention.
The report says doctors failed to consult neurosurgical experts at the nearest large hospital and a locum did not know the process for transferring patients at night.
It also identifies numerous cases of poor patient-documentation.
The West Coast District Health Board must review its procedures and report back to the commissioner by September 19.
