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A 33-year-old woman suffered two strokes while in hospital, and no one noticed.
Instead, she was sent home not once but three times in the space of just three days.
Canterbury District Health Board has been found in breach for failing to provide the woman with adequate care, a Health and Disability decision released today found.
The woman, who cannot be named for privacy reasons, went to the ED four times over three days for worsening neck pain and headache, pulsing noises, vertigo and vomiting.
At the first three visits she was diagnosed and discharged with a severe ear infection and migraine.
She was referred to the ear, nose and throat (ENT) service at the second and third visit but it was not until the fourth visit to ED that she was reviewed by a senior doctor and was given a CT scan, which revealed she had suffered two strokes.
In the report, the woman said she felt uneasy leaving the hospital and was in persistent pain.
Multiple doctors who treated the woman during this time acknowledged the failures with one saying he "sincerely regrets any shortcomings in his manner or attitude".
Canterbury DHB's chief medical officer Dr Sue Nightingale told the Herald today that the DHB accepted the findings and admitted its care fell short.
"Since this incident occurred, improvements have been made and we would like to reassure the public that we have made changes to reduce the chances of our systems and processes contributing to an incident like this again."
Health and Disability Commissioner Anthony Hill criticised the DHB for the lack of senior doctor involvement saying the consultant failed to show critical thinking and make the necessary active diagnostic inquiries.
"This case demonstrates the significance of the patient's voice and the importance of listening to the patient's experience," Hill said.
He also slammed the ENT service saying it had contributed to the delayed diagnosis of the woman's condition.
Hill said it showed a pattern of poor care and accordingly found the DHB in breach of the Code of Health and Disability Services Consumers' Rights.
As a result, Hill recommended that the DHB apologise to the woman.
He also made a number of other recommendations relating to the oversight and support of junior doctors and guidelines for when a patient returns to ED including when to escalate.