Marlene Joan Strongman, 78, died at Tauranga Hospital on June 23, 2010 from a brain injury secondary to pneumonia.
She was admitted on June 17, 2010 with a cough, vomiting, dehydration, irregular pulse and a two-inch lump in her groin after referral by her GP.
Coroner Dr Wallace Bain adjourned the inquest but not before declaring his view that "on the balance of probabilities" Mrs Strongman would still be alive if there had been appropriate interventions.
Mrs Strongman's death had already been the subject of a damning Health and Disability Commissioner report, which found the Bay of Plenty District Health Board failed in its duty to provide an adequate level of care.
Inadequate records, inconsistent and flawed clinical handover processes by medical staff involved and a failure to diagnose the abdominal hernia with bowel obstruction had resulted in breaches of the Code of Health and Disability Services Consumers' Rights, the report said.
Dr Bain heard submissions from the Strongman family and a representative from the Bay of Plenty District Health Board.
Mrs Strongman's eldest daughter Jane Taylor spoke on behalf of the family.
"It is our view that my mother's death was primarily the result of systemic errors on the part of the Bay of Plenty District Health Board, for which this organisation has failed to take responsibility in a meaningful way," she said.
She added that rather than accepting responsibility at an earlier stage, "the administrative arm of the hospital had attempted to cover up its failings. In doing so [it] has treated the family in an almost contemptuous manner."
Mrs Taylor slammed the health board's communication with the family after they complained to the Health and Disability Commissioner.
The family had expected health board chief executive officer Phil Cammish to attend the inquest to respond to their concerns, she said.
"Although the district health board has made some recent changes to its policies and procedures, it is our view that these changes will only be successful if they are accompanied by a radical improvement in professional attitudes by the hospital leadership and medical staff," she said.
Health board quality and patient safety co-ordinator Averil Boon said the health board accepted the level of care Mrs Strongman received was inadequate as were communications with the family.
She apologised on behalf of the health board. She outlined improvements that had been implemented, including a number of changes recommended by the Health and Disability Commissioner.
Dr Bain adjourned the inquest and called for written submissions from the family's lawyer and from the health board governance and quality general manager Gail Bingham.
This is the second inquest this week involving complaints about inadequate care of a patient at Tauranga Hospital.