A senior surgeon who operated on a woman who died of blood loss at Wairau Hospital was not told she had refused blood products for religious reasons, the public health watchdog says.
The case involved a woman in her 30s admitted to the South Island hospital for routine keyhole surgery in 2011 to remove her gallbladder, but had to have open surgery following a complication.
The woman bled internally, however, and the surgeon opted for a blood transfusion, only to be told that it was impossible as she had refused blood due to her religion.
The patient died within hours while waiting to be evacuated to a larger hospital.
Health and Disability Commissioner Anthony Hill said the woman was let down by poor systems and teamwork that meant the surgeon was the only person in the operating theatre who did not have that vital information about her.
Mr Hill told Radio New Zealand's Checkpoint programme today that the options should have been clearly discussed with the patient because of the consequences of a serious bleed.
Nelson Marlborough DHB chief medical officer Nick Baker said policies and procedures had since been improved.
"We've still got work to do around better training and education for our staff around beliefs and consent but the policy has been changed, our surgical checklist process has been changed so that it is very clearly something that's discussed in front of the patient prior to the procedure."
There was a less than 1 percent risk of complications but changes have been made in cases where consent was an issue, he said.
"Really, as soon as non-consent to blood products is raised, a completely different approach needs to occur.
"I think that wasn't overt in our thinking at that stage, in the sense that people were stuck on the 'oh, we don't bother about consent in the less than 1 percent."
The DHB and two doctors have been told to apologise.