Hutt Valley District Health Board has been criticised for its handling of emergency patients after a man who was not seen by medical staff died two weeks later.
Timothy McCrone, 51, collapsed at home in September 2007.
He had complained of shortness of breath for a year but, despite a number of visits to his GP and specialist, was never fully diagnosed.
In late August 2007 he was sent to Hutt Hospital's Emergency Department. After being given a form by the receptionist, he waited unseen for three hours, then left.
Wellington coroner Ian Smith said failures at the hospital and by his doctors cannot be blamed for Mr McCrone's death, but has recommended that the Hutt Valley District Health Board review its triage process for handling and recording patient details.
The coroner also recommended there be better reporting between specialist consultants and GPs so patients who are unwell are always dealt with by one or other doctor.
The head of Hutt Hospital's emergency department, Richard Makower, says Mr McCrone was neglected because no-one recorded his name.
Mr Makower says the system has been changed to help ensure people return the form with their name on it.
He says the hospital will soon begin building a better-designed emergency department.
