The public health watchdog says unsatisfactory communication between surgeons and others at Whanganui Hospital compromised the care given to an elderly man who died there.
The Health and Disability Commissioner has found two surgeons and the Whanganui District Health Board at fault in the case, in which an elderly man died in 2006.
A tube inserted following removal of the 85-year-old's gall bladder was meant to stay in place for a month but became accidentally dislodged well before then.
A second surgeon spotted the mishap but that key information wasn't relayed to the responsible surgeon until much later - after the patient was readmitted, needing further surgery.
Improvements since made, says board
The Whanganui District Health Board says changes have been made to improve patient safety since the man died.
Chairwoman Kate Joblin says the board accepts the findings but is disappointed that one surgeon in particular - known only as Dr C-- was found to have been at fault.
Ms Joblin says that changes have been made to ensure full information about patients is now available during ward rounds, and
that communication in general has improved. She would not comment, however, on communication between the two surgeons.