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.
In a report today, the Health and Disability Commissioner said the woman chose to leave hospital, adding she felt like she was going home to die.
Anthony Hill says the unnamed 35-year-old was taken to a hospital emergency department in mid-2016 with a pounding headache and extreme neck pain.
Busy ED doctors reviewed her three times but failed to ask for a CT scan, proposing a psychological assessment instead.
The woman went home, saying she felt she was not being taken seriously.
The tumour was diagnosed privately two months later.
Mr Hill said the woman recovered well, but the lack of a CT scan or review when she was first admitted amounted to poor care.
