Wellington, May 4 NZPA - A 75-year-old woman died less than four hours after a doctor at Whangarei Hospital misdiagnosed her chest pains and discharged her.

The Health and Disability Commissioner found that the doctor and the Northland District Health Board (NDHB), breached standards with her care.

The woman, named in the report only as Mrs A, was taken to the hospital in November 2008 after complaining of shortness of breath and chest pain.

She was treated by a medical registrar, named as Dr E, in the hospital's emergency department, where blood tests, an X-ray and an electrocardiogram (ECG) were ordered.

After examining Mrs A, and reviewing the results of an X-ray, an electrocardiogram (ECG), and the partial results of blood tests, Dr E was unable to ascertain a cause for her symptoms.

He discharged her with a diagnosis of panic attack about 1.38pm.

After returning home, Mrs A stopped breathing. Attempts to resuscitate her failed and she died about 5.19pm.

A post mortem was inconclusive as to Mrs A's cause of death, but found it was most likely coronary heart disease.

In a complaint to the former Health and Disability Commissioner Ron Paterson, Mrs A's son and daughter questioned the care provided by Dr E and the NDHB.

An independent emergency medicine specialist, Garry Clearwater, reported that Mrs A was discharged before the full blood test results were seen and without consultation with a senior doctor.

"In Dr Clearwater's opinion, the crucial issue was Dr E's decision to discharge Mrs A less than two hours after admission, preventing further observation and investigations to rule out more serious causes for her unexplained shortness of breath," Mr Paterson, who has since left his post, said.

"To his credit, Dr E has accepted responsibility for his mistakes, which have clearly had a profound impact on him, and has offered an apology to Mrs A's family. Nonetheless, I conclude that, by his omissions, Dr E breached...the code of the Health and Disability Services Consumers' Rights."

NDHB was also found to have breached its duty of care.

"Dr E did not receive adequate orientation, training, support and supervision. Northland DHB is also responsible for the systemic factors that contributed to Mrs A's misdiagnosis and premature discharge."

The report said the DHB did not have adequate systems in place to prevent doctors missing pending test results or to ensure that all relevant notes were included in a patient's file.

Mr Paterson recommended NDHB review its policies for training junior doctors.

The recommendations included implementing a policy that required locums and registrars working in emergency departments to discuss all acute discharges with a supervisor or experienced colleague.

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