The public health watchdog has criticised the Auckland DHB after a man referred to it for a heart scan died before getting treatment.
The Health and Disability Commissioner Anthony Hill says the DHB's systems let the unnamed patient down as he was assessed as "semi-urgent" based solely on information in a referral letter.
The DHB, and an unnamed heart specialist, failed to get a test result resent after the initial copy could not be read by staff.
If they had seen the results he would have been treated sooner, but he died weeks before his appointment.
Mr Hill said the DHB's staff did not obtain sufficient information to determine whether it was necessary to fast-track the man's treatment, did not seek a legible copy of the test results, and did not appropriately acknowledge the referral.
The DHB which referred the man, which was not named, should have also ensured the referral was received and actioned, Mr Hill said.