A 75-year-old woman was prescribed two incompatible medications by the Lakes District Health Board (DHB) before she died.
The woman was taken to an emergency department in 2016 feeling unwell with a headache, shortness of breath and other symptoms.
A report released on Monday by Health and Disability Commissioner Anthony Hill finds the DHB administered a blood-thinning medication known as enoxaparin on her third day in the hospital, in case she had pulmonary embolism (PE) - often a blood clot which can become wedged in the artery and lungs.
She was then given dabigatran - another blood-thinning medication - on day four. Either medicine can be used to treat PE, but "they should not be administered together".
Hill says the potential medication error may have contributed to the woman's deterioration.
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The woman, who's identified as Mrs A was transferred home after seven days in hospital, where she died a short time later.
Hill says services were not provided to Mrs A with reasonable care and skill. He says issues regarding education, guidelines, and policy implementation at Lakes DHB were identified.
He criticised the DHB for using the medications together, adding the manner in which the error was disclosed "was not ideal".
The doctor in question has since made changes to her medical practice, while the Lakes DHB conducted a review of the medications prescribed and dispensed to Mrs A.
A further two incidents of co-prescribing, the medications in question, were also identified within weeks of Mts A's case, according to a root cause analysis review conducted by the DHB in 2017.
Hill recommended the DHB take steps to improve its documentation and decision-making about the appropriate prescribing of anticoagulants.
He also recommended the DHNB updated anticoagulant guidelines, and provide a written apology to Mrs A's family.
According to the report, the DHB has taken the incident seriously, and has used the case to improve its processes, procedures and guidelines.