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An elderly woman died after a "rude and disrespectful" doctor misdiagnosed a massive stroke as a headache and sent her home instead of to hospital.
Health and Disability Commissioner Ron Paterson has referred the GP to the Medical Council to review his competence but recommended no further disciplinary action be taken.
The review said the "fit and well" 79-year-old was "overcome with severe pain in her neck and head", so her daughter rushed her to an accident and emergency clinic in August last year.
The doctor carried out an examination and diagnosed sinusitis - headache pain in the forehead - after eliminating a stroke as the cause.
The North Shore woman was taken home even though "she could not put one foot in front of the other".
However, when her daughter returned the following morning no one answered the door. She found her mother semi-conscious in bed, covered in vomit and her own waste.
The woman was taken to North Shore Hospital in an ambulance, where a CT scan confirmed she had suffered a massive stroke. Her condition deteriorated and the woman died a few days after being moved to a private hospital.
The Health and Disability Commission (HDC) received a complaint before the woman died.
In his final report, Paterson found the doctor breached the Code of Health and Disability Services Consumers' Rights by a lack of care and rude behaviour.
"There were important clues to her stroke, including the sudden onset of her severe headache, her lack of history of severe headaches, her age and medication for high blood pressure," said Paterson.
Dr Simon Brokenshire provided expert medical advice to Paterson as an accident and emergency specialist.
In his opinion there were "red flags" but the case was not straightforward.
"However, in an elderly woman with a severe headache of relative sudden onset, I feel on balance this history alone warranted a more cautionary approach.
"It is my view that [Dr B] did not provide diagnostic care of an acceptable standard for an accident and medical specialist making a diagnosis related to acute onset of severe headache."
Dr B told the HDC investigation he was now more vigilant and "conservative" in his approach and had a "lower threshold" for referring a patient to hospital.
However, these changes were of "no comfort" to the deceased patient's family, said his daughter. "My mother's final hours of consciousness were spent alone, scared and more likely in great pain, instead of in hospital with family around," she told the HDC investigation.
"We are passionate about trying to prevent anybody else going through this trauma."
Paterson also criticised the "rude behaviour" of the doctor, who threw the woman's medication on the ground when she asked questions during the examination, telling her to "forget about it" in an impatient manner.
Dr B said he dropped the medications on the floor "in a small piece of theatre... in an attempt to try and refocus the consult".
Paterson criticised the behaviour as "rude and disrespectful".
"This was unprofessional behaviour and cannot be excused as banter."
A Medical Council spokesman could not comment on the specific details of a GP's review.
