Delays in diagnosing and treating a woman's cancer contributed to her death at Hutt Hospital, according to Coroner Garry Evans.
Anita McCall, 48, was referred to the hospital in January 2005 but not seen by a specialist until March 2006 after complaining of severe bowel pain.
Mr Evans, who issued his findings on the case on Tuesday, says Ms McCall should have been seen within four months.
Her case was assessed as semi-urgent, but it took 13 months for an appointment to be arranged with a specialist.
A family doctor wrote to the hospital three times before getting an appointment for Ms McCall.
She was eventually diagnosed with bowel cancer, which had by then spread, and died during an operation at Hutt Hospital in August 2006.
Mr Evans says her file was "lost" in Hutt Valley District Health Board's administrative system at a time when many patients faced long waits for non-urgent treatment.
He says the health board has apologised and has since done all it can to ensure fasterer treatment for such cases in future.