The Health and Disability Commissioner has found that the Waikato District Health Board failed to provide adequate services for a three-month-old baby who later died.
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The baby was diagnosed with laryngomalacia and was referred to the emergency department of one of the DHB's hospitals in 2015.
Laryngomalacia is a condition where the tissues just above the vocal cords becomes floppy and cause obstruction to airways in the throat.
An examination of the larynx and throat was scheduled, but was later cancelled.
The DHB was unable to explain why.
The baby was discharged without any follow up care from paediatrics or ear, nose and throat specialists and died 24 days later.
A coronial report found the cause of death was respiratory failure.
Health and Disability Commissioner, Anthony Hill, said the Waikato DHB failed in its care of the three-month-old for the following reasons:
"A 'scope' [examination] did not occur in hospital or shortly after discharge at an outpatient clinic. The baby did not receive consultant-level ENT [Ear, Nose and Throat] review, even though this was requested by the paediatrics team. In addition, it is unclear whether there was any form of senior ENT input into the baby's management," he said.
"There was poor documentation around key decision-making points, including the decision not to 'scope' and the decision to discharge. A number of staff across both the paediatrics and ENT teams documented their care poorly. The baby was discharged without a formal diagnosis or a plan for specialist follow-up care, either with ENT or paediatrics."
Mr Hill has given the Waikato DHB a number of recommendations including apologising to the family of the baby and carrying out audits of how cases involved children are dealt with at the hospital.