Doctors at Capital and Coast District Health Board failed to order a brain scan for a woman with a brain tumour, insisting instead on a psychological assessment.
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In a report today, the heath watchdog said the woman felt she was not being treated seriously and left hospital, against medical advice.
She told the Health and Disability Commissioner, Anthony Hill, she felt unsupported: "I felt like I was being sent home to die", adding she had decided to leave hospital because of her baby's needs.
The events occurred in July 2016, when the 35-year-old woman was taken to hospital by ambulance with a pounding headache, fatigue, extreme neck pain, leg and arm paralysis, vomiting and hot and cold sweats.
Mr Hill said in the report that the woman - known only as Ms A - was reviewed, but a doctor decided she "did not require a CT scan of her head and neck imminently, but that scanning could be considered as part of further assessments".
Ms A was referred to the general medicine team which also decided no CT scan was needed.
Questioned about this later, one of the unnamed doctors involved said: "It may be that the combination of workload, pressure to discharge patients in order to reduce overcrowing in the ED, and the fact that [Ms A] had improved overnight led to my downplaying of the red flags present the day before, and hence not to order a CT scan."
Ms A told Mr Hill she did not agree with the diagnosis she had been given but felt "helpless and vulnerable". She added that if her sympotoms did not improve she was concerned about her ability to care for her baby.
Ms A was back in the ED two months later, in October 2016, for a seizure and loss of consciousness. She complained that her symptoms were a lot worse, but a doctor she saw this time said blood and urine tests and an electrocardiogram (ECG) were normal, but a psychiatric referral may be needed.
Two more medical reviews took place before Ms A decided she wanted to go home, against medical advice.
Mr Hill says: "Ms A stated that when Dr C tried to convince her that her symptoms were psychological, she began to doubt herself and to question her own sanity. She said that she felt unsupported, and that she was not being taken seriously. Ms A stated: 'I felt like I was being sent home to die.'"
In mid October 2016, Ms A was referred by her family doctor to neurology outpatients and was seen by a neurologist in private practice. She got an MRI scan which revealed the brain tumour.
Mr Hill said in his report that she is recovering well from the surgery and feels stronger every day. "However, she feels that it was unfair for the doctors in the ED to push their diagnosis of postnatal depression just because she had a baby and a recent family bearevement. She considers that the doctors should have investigated further and undertaken an MRI scan."
Mr Hill agreed, saying the DHB and a doctor involved breached patient rights. Said Mr Hill: "... the standard of care for a patient with these symptoms would be to query a brain or spinal cord mass or lesion, and either obtain imaging in the ED or refer the patient to general medicine or neurology. He said a CT scan should have been ordered when it was thought to be needed, or an urgent neurology clinic review.
Mr Hill said the failures amounted to "a pattern of poor care".
The Capitial and Coast DHB told RNZ the care provided was unacceptable and it has apologised. It added it is considering how it might implement Mr Hill's recommendations.