A coroner has found drug administration errors and indecision over surgery were factors in the death of a West Coast man.
Geoffrey David Mehrtens, 54, died in Christchurch hospital in early 2010 of multiple organ failure.
Mr Mehrtens was in and out of Grey Base and Christchurch hospitals with a chronic infection and other serious medical problems in 2009.
Coroner Richard McElrea said there was a missed opportunity to operate on the infection and an error and lack of monitoring of drugs occured shortly before his death.
The Health and Disability Commissioner decided in 2013 not to take any action against the DHBs involved.
Canterbury District Health Board said systems are now in place to address the shortfalls in care found to have been factors in the death of Mr Mehrtens.
Chief medical officer Nigel Millar said he was confident new systems for sharing care information and getting health boards working together had made it less likely something like this will happen again.