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A woman found dead in her South Island home had been misdiagnosed a day earlier by her doctor, who failed to pick up signs of pneumonia.
Stephanie Mihi Parata's partner found her body slumped on the toilet in the Totara Hostel where they lived in Motueka on March 9, 2016.
A day earlier 42-year-old Parata had visited Dr Gerda Bruinsma saying she was short of breath and had been sweating at night and coughing for three days.
Bruinsma diagnosed Parata as having sinus tachycardia, believing her rapid heart rate was due to anxiety from her battle with alcoholism.
But expert testimony given by Dr John Clark to a coronial inquest into Parata's death found Bruinsma did not go far enough in trying to diagnose the reason behind Parata's faster heart beat.
"Proper investigation" into the cause of the rapid heartbeat should have included a check of Parata's temperature, blood tests, a chest x-ray to check for pneumonia and a further check known as D-dimer.
He said pneumonia was a threat to people battling alcoholism because they tended to have weakened immune systems.
"These tests should have been done urgently and the patient kept under close observation until the diagnosis was clear," Clark told Coroner Elliott during the inquest in Christchurch, whose findings were released this month.
"If it was late in the day and test results known to take longer to be reported than end of the clinic working day, consideration should have been made to have the patient transferred to the nearest hospital and there kept under observation."
Bruinsma, instead sent Parata home unobserved with medication, telling her to come back if she didn't feel better.
At the inquest, Bruinsma accepted she had misdiagnosed Parata and apologised to her family.
She also "expressed her regret that she did not refer her to the Emergency Department at Nelson Hospital that day", Coroner Elliott wrote in his report.
She told the inquest that with hindsight she wished she had done further tests and "deeply regrets" the death of Parata.
The Health and Disability Commissioner found in its own report Bruinsma had breached the medical code of care to Parata "by failing to take Ms Parata's temperature and to recognise the seriousness of her symptoms and to take appropriate action in response".
However, Bruinsma had stopped practicing medicine since Parata's death and was no longer in breach of the code, Coroner Elliott found.
Bruinsma had now also formally apologised to Parata's family as recommended by the Health and Disability Commissioner.
Parata's family had wanted an apology immediately after the 42-year-old's death but Bruinsma told the inquest that she had been told not to make contact with them, despite wishing to speak to them.
With the Health and Disability Commissioner publishing a copy of his findings from the case for educational purposes, Coroner Elliott said he did not consider it necessary to make any further recommendations.