A Wellington coroner has reiterated concerns he has with hospitals and their lack of communication with the families of patients.
Coroner Ian Smith made these comments after an inquiry into the death of 56-year-old Katherine Cains who died in Lower Hutt Hospital on December 26, 2010.
Ms Cains, who had multiple medical issues, was taken to Lower Hutt Hospital with bowel and lower abdominal problems on December 13, 2010, but was discharged later that day.
Five days later she returned to hospital with similar problems and was operated on that evening.
But on the afternoon of December 26, Ms Cairns was found dead in her hospital bed by a nurse. She died of abdominal sepsis.
Following her death Ms Cains' sister raised several concerns about her sister's treatment, particularly the lack of communication between hospital staff and her family.
Ms Cains was a very sick woman and her sister said someone should have spoken to her about Ms Cains' condition so she could then let the rest of the family know.
In the report released today, Mr Smith said he had concerns about what appeared to be a lack of dialogue between hospital staff and families.
He has previously raised the same concern in several inquiries.
Mr Smith reiterated comments made by Robert Logan, the now retired chief medical officer at Hutt Hospital. During an inquest into the death of 85-year-old Kathleen Corbett, Dr Logan said the health system was not as sound and open as it should be in dealing with patients' future prospects.
Families needed to be told in a "truthful manner" how their loved ones were and that they could die, so they were prepared for it, he said.
Following the complaint laid by Ms Cains' sister the Health and Disability Commissioner, Anthony Hill, became involved and a mediated settlement was reached between the family and hospital.
Part of the process with the Commission was to deal with the lack of communication, and the DHB said it would produce a pamphlet which set out patients' rights and who to contact if there was a problem.
However, Mr Smith said he had no evidence that such a pamphlet was produced but he hoped that it would be.
"It would be most helpful and also act as a prompt to the hospital staff about the importance of communication with family caregivers of a patient."