A medical specialist and a district health board could face disciplinary action after failing to find hearing problems in two children.
Deputy Health and Disability Commissioner Theo Baker has referred the cases for a review that will decide if the un-named audiologist and their employer, the Southern District Health Board, will face disciplinary action.
In one case, a young boy's hearing problems went undiagnosed for 10 years, despite the audiologist seeing him five times over the period.
The second case involved a three-year-old girl who was found to have problems, but no follow-up appointments were made. A second specialist found significant hearing loss in her right ear.
As well as problems with the audiologist, Theo Baker found that the DHB had failed to provide peer support and carry out checks.
Ms Baker also found the health provider's equipment to be sub-optimal.