A coroner has recommended Nelson Hospital improve its system for handling medical records, following the death of a woman in 2007.
Glenys McLay, 49, suffered rare complications after undergoing brain surgery, but medical notes were not available to staff who treated her.
Coroner Ian Smith has recommended the Nelson Marlborough District Health Board urgently introduce a planned electronic record system, and use a duplicate notes system in the meantime.
Mr Smith also recommends CT scans be available on a round-the-clock basis.
The district health board says it has made significant changes since the death.
Chief medical adviser Dr Andre Nel says an electronic medical records system has been introduced
He believes enough improvements have been made, and it would be very unlikely for the situation to be repeated.
Dr Nel says it was a tragic event and the board has apologised to the family.