The rare death of a patient due to a listeria infection is one of seven deaths at Hawke's Bay Hospital highlighted in a report by the Health Quality and Safety Commission.
Among the deaths detailed in yesterday's findings was a baby who died just three hours after an emergency caesarean section, a suicide, two deaths following falls, a patient who died after developing septicemia and an unexpected death after a patient was admitted with pancreatitis.
In the later case, seven separate issues with the patient's care was identified, including failure to recognise the deterioration, inadequate pain management and no CPR initiated.
After the patient died there was a delay in the completion of their death certificate and mortuary transfer.
The report showed a total of 11 serious and sentinel events for Hawke's Bay's DHB.
Six of the cases related to falls.
Two cases have been referred to the coroner.
The Public Health Unit and the Ministry of Primary Industries were still investigating the listeria death.
Chief medical officer John Gommans said serious and sentinel events were "always extremely distressing" for patients, their families and staff.
"As a DHB we are always looking for new ways to further reduce avoidable harm and one of the most important things a healthcare organisation could do was provide an environment where transparency was paramount so learning could come from these tragic events," Dr Gommans said.
The commission's chairman, Professor Alan Merry, said not all the events described in the report were preventable, but many involved errors that should not have happened.
Hawke's Bay DHB serious and sentinel events