Hutt Hospital staff did not understand the needs of a severely disabled woman who died of an undiagnosed infection, an investigation has found.
The 52-year-old, who worked with the Health Ministry's disability policy team, suffered spinal muscular atrophy and was partially paralysed.
Following her death in May 2008 an independent review was commissioned by the Hutt Valley District Health Board.
Having encountered problems during previous hospital stays, the woman had met with doctors, managers and health board members to create a support plan which would be implemented during future visits, The Dominion Post reported.
However, the review found that while staff had tried to provide nursing care, they had "little understanding" of her needs.
Staff considered her demanding and were reluctant to respond to her requests for help.
Six days into her stay a dietician noticed a naso-gastric tube was draining away food as she ate it. Four days later the tube was still in place.
After two weeks a feeding tube was inserted into her intestine.
The woman complained of pain but there was no consideration of whether the procedure had caused a bowel perforation.
She died four days later from peritonitis, brought on by a small cut to her bowel from the tube.
The report said it was not clear whether the woman could have been saved through early detection as her weakened condition would have made it hard to fight an infection.
The health board said the review had been 'a significant learning experience" and led to major changes.
During her stay, the woman was seen by 27 different people, including 15 nurses, many of whom were casual staff.
The health board has since appointed more permanent workers and reorganised the medical ward to form smaller teams with a senior nurse to oversee the care of each patient.