The Capital and Coast District Health Board has been slammed for its treatment of a three month old boy who's been left blind, deaf and quadriplegic after doctors twice failed to correctly diagnose him.

Derek and Wendy Burton took their son William to hospital three times before his bacterial meningitis was found in 2013.

The first time they were told William had a fever of unknown origin, and they were told to come back to hospital if he got worse.

A day later a senior paediatric house officer, whose name is suppressed, diagnosed a gastro bug, even though William had hardly vomited and had no diarrhoea.

A senior paediatrician was consulted by phone, but trusted the diagnosis of the house officer and didn't see the child in person.

Crucially, no blood tests were ordered because it was thought they would be uninformative.

The Burtons were told William could have a fever for up to five days, so they went home expecting him to be unwell for a while.

It was only when they returned to hospital a third time four days later that meningitis was discovered, and it took a further two weeks for the consequences of the disease having gone untreated to become apparent.

Now two, William has needed life support five times in the last two years.

However, because his life expectancy has been slashed, the next time he needs mechanical ventilation, he can't have it.

A Health and Disability Commissioner report out today has found Capital and Coast DHB failed to provide adequate care.

It says meningitis is often missed the first time a patient sees a doctor, but what happened on the Burton's second visit is less excusable.

The report says while the senior paediatric house officer assessed William with the expected degree of knowledge and skill for someone with their level of experience, there were no clear instructions on what to do if things got worse.

It says opportunities that could have resulted in an earlier diagnosis were missed, though the senior paediatrician's decision not to see William in person was reasonable.

The HDC report says the possibility of blood poisoning wasn't given due weight.

It says there was a lack of recommendations of what to do for a child with William's symptoms and not enough consultation with a senior doctor.

More intensive international guidelines had been issued just a month prior, but hadn't been circulated to CCDHB staff at the time.

CCDHB accepts the findings, and has implemented recommendations for senior doctors to assess children in person if they return to hospital within three days.

It's apologised to the Burtons, and says it's saddened by the injury and disability that resulted.