Wellington Hospital has been criticised after a woman died after making four visits to the emergency department over 10 days, last year.
The woman, 72, reported slightly different symptoms each time, before dying in hospital after being diagnosed with a thoracic aortic aneurysm. The aneurysm ruptured before she could be operated on.
One of the nine doctors who saw her has told the Health & Disability Commissioner that she tried to admit the woman to the coronary care unit, but no beds were available.
The doctor says there was also a laboratory workers' strike on at the time.
The Commissioner says "red flags" were missed by medical staff and found she received sub-optimal care.
Commissioner Ron Patterson has recommend that hospital staff learn more about thoracic aneurysms, which he acknowledged are rare and hard to diagnose.
The Capital & Coast District Health Board has apologised to the family, and has acknowledged the commissioner's findings.