The treatment of a 63-year-old County Fermanagh woman who died in Belfast City Hospital has been criticised by the Northern Ireland Ombudsman.
Tom Frawley criticised the hospital in his report into the death of the woman, identified only as 'Mrs M.'
She was extremely ill when she was transferred from the Erne Hospital in December 2001, but was allowed to discharge herself two days later.
He said this was a "gross error of judgement".
Mr Frawley said he regarded it as "serious maladministration" in her treatment.
The woman's son took her back to Accident and Emergency five days later because she was in severe pain and her left leg was extremely swollen.
She was not admitted despite being exceptionally weak and not fit to travel home, said the ombudsman.
The following day she was taken back to the hospital, seen by the same doctor and admitted.
Her condition was monitored for several days by medical staff concerned about deep vein thrombosis in the woman's left leg - before a procedure was carried out after five days.
The woman died 48 hours later from suspected pulmonary embolism.