The Canterbury District Health Board has been told it should apologise to a woman who went to the emergency department four times before it was discovered she'd had two strokes.
Health and Disability Commissioner Anthony Hill said the woman went to hospital four times over three days, with worsening neck pain and a headache, pulsing noises, vertigo and vomiting.
At the first three visits, she was diagnosed with a severe ear infection and migraine and discharged. The woman said she felt uneasy leaving the hospital and was in persistent pain.
She was referred to the ear, nose and throat service, but it was not until her fourth visit that she was seen by a senior doctor or given a CT scan.
That scan revealed she'd had two strokes.
Mr Hill said the doctors failed to show critical thinking and make the necessary diagnostic enquiries, despite the fact the woman kept coming back with concerning unresolved symptoms.
"This case demonstrates the significance of the patient's voice and the importance of listening to the patient's experience," he said.
As well as recommending an apology, Mr Hill made recommendations about the oversight and support of junior doctors, and guidelines for when a patient returns to the emergency department, including when to escalate.