A Rotorua-based district health board failed to properly monitor a doctor who was rude and facing serious competency worries.
Health and Disability Commissioner Anthony Hill says Lakes District Health Board must apologise over the doctor's failures.
The doctor was already the subject of five complaints to the DHB when a male patient was admitted to an emergency department in 2011 with chest and shoulder injuries after falling onto concrete.
X-rays did not reveal anything, and the doctor, aware that the man had drunk a bottle and a half of wine, prescribed pain relief and an early discharge. Further tests ordered later found serious rib and lung injuries.
Mr Hill said the doctor provided poor care and was rude and unapproachable, while the DHB failed to ensure that she was competent and didn't monitor her performance adequately.
"My view is that more structured oversight and monitoring would have been appropriate, and I note that the DHB accepts that supervision should have been more robust in this case."
The Lakes District Health Board said it is making changes. Chief executive Ron Dunham said the situation occurred at a small hospital where supervision of less experienced staff was inadequate.
"One of the things that we have done is put a permanent medical director in at this hospital so that he is much closer to the doctors that are practising there."
The doctor is no longer working in New Zealand.