The daughter of an elderly woman, who died while in the care of the Waitematā District Health Board four years ago, says her mother's death was violent and traumatic.
Aileen Aspden, 83, was admitted to North Shore Hospital in late 2015 over a relapse of her Crohn's disease.
In a report on Monday, health watchdog Anthony Hill said junior staff failed to appreciate the seriousness of her condition and did not involve senior staff.
He said that resulted in poor decision-making across multiple specialities, ending in a failure to rescue a patient who'd been losing blood.
One of Mrs Aspden's daughters, Karla, has spoken out about her mother's death.
"One phrase that sticks with me from the reports is 'failure to rescue'. My mother was on a life raft and they did not rescue her," she said.
"They had every opportunity to extend her life and she was denied that. She was also denied a peaceful death - it was violent, traumatic and unwarranted."
Karla Aspden said there appeared to be a lack of staff on the general medical ward, and communication was poor.
"She was in this mixed ward, it was a hodge podge of conditions - I don't even think they had a real understanding of her condition or what they needed to do," she said.
"There was just no clear communication between the different bodies about what they need to do and how to effectively manage the pain and what was going on with her."
There was no single person to blame for her mother's death, Ms Aspden said.
"I blame the lack of staffing in hospitals, I blame the lack of communication and I blame a medical hierarchy where junior doctors either feel too arrogant or too scared to consult senior doctors, I blame senior doctors who don't take junior doctors seriously, I blame doctors who don't listen to nursing staff and take their concerns seriously."
The family has received an apology from the DHB, which said it deeply regretted that it did not provide the level of care that it expects.
Chief medical officer Andrew Brant said a number of changes had been made in the aftermath of Mrs Aspden's death, that significantly reduce the likelihood of a similar incident happening again.
- A programme that helps identify patients whose condition is deteriorating, including escalation pathways for rapid clinical decision-making. The DHB has made this system electronic, so senior staff are instantly alerted and can intervene quickly.
- A major reconstruction of general medical services, where dedicated medicine teams are assigned to a specific ward, enabling better communication about each patient while enabling a multi-disciplinary approach to care and increasing the ability for rapid responses to changing circumstances.
- The deployment of a new tool for structured clinical communication between doctors.
- The introduction of the Kōrero Mai (Talk to Me) initiative, creating a clear pathway for patients, family and whānau to communicate with those in charge if they are concerned about changes in a patient's condition.