She was referred to Whanganui Hospital for an assessment by her GP, however an orthopaedic surgeon at the hospital was unable to read the referral.
The surgeon therefore did not triage the referral and the woman went back to her GP, who referred her on to a podiatrist for an urgent assessment.
Her case was passed on to the district nursing service for care of the wound, and back to the hospital for further assessment. Later that month a surgical consultant at the hospital triaged the referral as semi-urgent.
District nurses who visited the woman during March and April noted the wound was very painful and requested a specialist assess the wound.
However when the specialist said the patient needed urgent vascular assessment, a consultant at the hospital was not made aware of the multiple other referrals.
He triaged the referral as "semi-urgent" and the relevant appointment was made for May.
A nurse fast-tracked this to the next month, but with continued visits failed to assess pain and escalate care.
When the patient showed for appointment at the end of May she was diagnosed with critical limb ischaemia - a severe obstruction of the arteries which reduces blood flow to hands, feet and legs and can cause ulcers or sores.
"Various limb salvaging procedures were performed, but Mrs B suffered complications and passed away," the report read.
Following the report's findings it was recommended the DHB promptly provide updates of a new "clinical portal" system as well as create and implement a training system programme for district nurses on pain management.
Hill also recommended the DHB and one of its nurses provided a written apology to the patient's family for failings identified in the report.
"The apologies are to be sent to HDC within three weeks of the date of this report, for forwarding to Mrs B's family. RN D has already provided an apology," Hill wrote.
Whanganui District Health Board's director of nursing Sandy Blake said hospital staff were taking all of the recommendations listed in Anthony Hill's report, on board.
The Health Board had fully implemented clinical portal - an IT system into which nurses wrote patient notes.
"This system allows health professionals to track the patient journey and allows all clinicians to see the same notes," Blake said.
Nursing staff had undergone training and an auditing system would measure compliance.
Blake said the nurses whose practise was deemed to be unsatisfactory, were being managed through the DHB's performance management process.
The investigation and Hill's report into the inquiry was prompted by a complaint from the patient's son.
His mother had suffered from type 2 diabetes as well as several other health issues and had lived at home with weekly home help.
The particular right that the report stated had been breached was the patient's right to have services provided "with reasonable care and skill".
