A university student with facial fractures went to a hospital emergency department demanding an x-ray but was told they were too busy.
In a report today, Health and Disability Commissioner Anthony Hill said the Auckland District Health Board breached patient rights over the case in 2015.
The first-year student, Ms A, had been unwell for four days with flu-like symptoms. Overnight on 13 September, 2015 she fainted twice, hitting her face on a brick wall the second time and hurting her right thumb.
She went to a hospital emergency department by ambulance that night, with the ambulance officer noting she had pain in her face and right thumb.
At hospital she was triaged then examined by a senior house officer, Dr C, who focussed on the possibility of a head injury but did not pick up on the facial injury. He told Mr Hill later that Ms A had not mentioned facial numbness, which would have triggered alarm bells for him.
Ms A stayed in hospital overnight and was discharged next morning. She said that as she walked home she felt hot, nauseous and dizzy, with her face and mouth "completely numb". She added she was having difficulty standing up and walking owing to dizziness and blood coming from her nose continuously.
She returned to the hospital ED with a friend and an assistant at the hall of residence where she was staying, who later told Mr Hill the student "looked terrible, was pale, clammy and 'coherent but not by much'".
Mr Hill said Ms A had asked for an x-ray but was told by someone on the front desk the ED was very busy that night and there was limited bed space so those in the worst condition would be admitted first.
Ms A added that this woman had emphasised she had been diagnosed with flu, "and told me to take paracetamol and not come back unless you start vomiting multiple times".
Ms A returned home, having numerous facial fractures diagnosed by x-ray later following a referral to a public hospital in her home town, and corrective surgery by a maxillofacial surgeon.
She added the delayed diagnosis cost her and her family financially and affected her university education.
"Even though I am not a medical person, after sustaining an injury such as I did, I would have thought that x-rays and facial examination would be standard practice," she said.
Mr Hill said the Auckland DHB "ought to have triaged the woman when she re-presented to ED, and in not doing so, it failed to provide her with services with reasonable care and skill".
He was also critical that there was no record of the woman's second presentation at the ED, except for a medical certificate, and that the DHB had been unable to identify the staff member who spoke to Ms A.
He said while the care provided by Dr C did not breach patient rights, he did not pick up that there could be a facial injury and did not discuss the woman's case with a senior doctor prior to discharging her.
Mr Hill said these were "individual clinical errors in decision-making" by Dr C and not a failing by the DHB.
Mr Hill recommended the DHB report to his office about the implementation of its mentoring programme for junior staff, on its review of the ED triage process and with evidence of training sessions on triage.