An elderly woman died as a result of complications after her leg had to be amputated because health professionals had failed to treat her sore foot.
The Health and Disability Commissioner said the Whanganui District Health Board and two district nurses must apologise to the 80-year-old's family, introduce new clinical information systems and undertake extra training.
After injuring her right foot, the woman visited her GP who referred her to Whanganui Hospital.
But the referral was returned, because it was illegible.
The GP then referred the woman to a podiatrist, who referred her back to the hospital.
District health nurses also referred the woman to the hospital.
The hospital treated all the referrals as isolated cases.
The woman's leg deteriorated and doctors were forced to amputate it below the knee.
She died from complications.