When a teenager was taken to a nationwide hospital after a car accident in 2014, the staff thought she was drunk.
Only after complaints from family and a blood test requested by the police, there was no alcohol in her system that the woman was transferred to the intensive care unit of the city hospital, where she later died.
The findings were part of a report of 108 pages published by Anthony Hill, a member of Health and Disability, after the family of the woman had complained about the care provided.
Mr. Hill said that the ambulance service, the rural hospital, a national doctor and two nurses had failed the teenager and had been negligent.
The 18-year-old woman was part of a car accident on the east coast. The other occupant of the car was also injured, but was transported to a city hospital.
A paramedic of an emergency medical technician transported the woman to a national hospital without assistance. She was admitted around 4.45 am.
Upon her arrival she was unable to bear bear, she expressed pain and was reportedly drunk.
The national GP in the hospital said that the woman would not be transferred to the city hospital because she was drunk.
Next, a nurse performed baseline observations on the woman, but did not complete any neurological observations. The doctor assessed the woman and said she did not have a clear brain injury.
During the morning shift, broken glass on the woman's back was not removed and her hygienic needs were not taken care of.
When the registered nurse provided her transfer to a second nurse, she failed to provide information about the patient.
The second nurse failed to make observations or to set up cooling for about six hours, and she was given no food or a means to moisturize.
Only when the family expressed her concern did the second nurse contact doctors and eventually she was transported to a city hospital.
The woman underwent brain surgery and received brain-oriented intensive care therapies before she died in the hospital.
The report said that the doctor and the two nurses all made retrospective additions to the clinical data without mentioning them as such. The second nurse also removed original notes from the woman's file.
Hill said the ambulance service failed to provide the woman with reasonable care and ability and not to recognize the seriousness of her condition.
He said the first doctor did not recognize the "significantly abnormal" neurological condition of the woman, and stated that her failure to improve over time suggested that alcohol was not an explanation.
The first nurse failed to complete neurological observations and an assessment of the woman's blood glucose level, which Mr. Hill said was another failure, while the second nurse did not check her vital signs for several hours.
He was worried about how the second nurse could not manage the hygiene, food and hydration needs.
The doctor involved has been instructed to undergo a performance assessment and there can be an assessment of the competence of the two nurses.
Hill has referred the ambulance service and the owner of the national hospital to the Proceedings director to decide whether further action should be taken.
He also recommended that those involved apologize to the family.