A 38-year-old man died of respiratory failure despite repeated visits to his GP over five months, plagued by a severe cough.
The Health and Disability Commissioner said the GP failed to advocate appropriately for his patient.
In a report published today, Anthony Hill said the man consulted his unnamed GP in 2013 over coughing fits, especially at night.
The doctor prescribed antibiotics and later requested a semi-urgent referral to a specialist respiratory service.
The man's coughing worsened and the GP said he had made a new, urgent referral, but there was no evidence this was done.
The day before the man died, the GP saw him and prescribed an antibiotic but did not physically examine him.
By failing to follow up his initial referral or update the DHB about his patient's deterioration, the GP provided sub-optimal care, Mr Hill said.