A coroner has found it extraordinary and unacceptable that a mentally ill woman was left to die in her room at Auckland Hospital.
Maria Richardson, who was 60, was admitted to the hospital's mental health unit in July 2007. She died from heart problems after being left unattended for 15 hours.
Ms Richardson had an extensive history of chronic paranoid schizophrenia and was physically and mentally unwell when she was admitted to the hospital.
Staff assessing her decided against transferring her to a medical ward, and nurses were told to check on her regularly.
The report says nurses did so by looking through the window of her door.
The Coroner says staff failed to look after Ms Richardson properly, and mental health patients should have the same standard of medical care as patients in other wards.
The Auckland District Health Board says it has already made significant progress on addressing the recommendations.
Director of Mental Health Dr Clive Bensemen says a new observation policy has been brought in and a nurse specialist appointed to upskill nursing staff. He is confident a death would not occur again under the same circumstances.