The Auckland District Health Board and an unnamed DHB have been criticised over their handling of a patient who died awaiting treatment for serious chest pain.
The man suffered from angina and would have been seen sooner if a cardiologist at the Auckland DHB had asked for illegible test results to be re-faxed so he could read them.
In findings released on Monday, Health and Disability Commissioner Anthony Hill on Monday faulted the Auckland DHB and censured the other district health board.
Crucial test results about the man were faxed from the second DHB to Auckland, but were illegible and not taken into account.
The heart specialist receiving these results relied instead on another report, which failed to alert him to the seriousness of the situation.
This specialist says the letter understated the case and the referring doctor should have phoned him directly.
The man was assessed as semi-urgent only and died in 2009 awaiting his appointment.
Mr Hill says the Auckland DHB should have sought the full details and the other DHB should have ensured that they had been received.
The Auckland DHB says it will implement the recommendations.