Six weeks after her assessment, a transplant nephrologist from Auckland District Health Board typed a letter to her renal physician at Waikato District Health Board.
However, the board did not get the letter until August 13, two weeks after it was typed up.
The Waikato physician referred her back to Tauranga, but the letter was erroneously sent to Waikato, which declined the referral because the tests she needed were available in Tauranga.
She was booked in in Tauranga where the doctor referred her for more tests and deferred to another doctor the decision on whether a cardiac MRI could be done safely. After another test, an MRI was considered unsafe so Waikato doctors requested a different scan.
The results of the scan were normal so at the start of January 2013 they were sent to the Transplant Group who were asked to confirm they were satisfied with the cardiac assessment.
The group never responded to the letter and told the commissioner Waikato Hospital staff would usually put the patient on the agenda for an Auckland Regional Transplant Group meeting when they were satisfied a patient was a good candidate.
On March 4, the woman's case was considered again by Waikato doctors - more than 11 weeks after her last test. But nothing more was done until the Bay of Plenty District Health Board requested an update in mid-April.
She was again presented to the Transplant Group in May and they requested further cardiac review and an MRI was again ruled unsafe.
The Transplant Group put her on to the deceased donor list on June 11.
Soon after, initial tests suggested the daughter could be a suitable donor but about that time key Waikato Hospital staff went on unplanned extended leave and the remaining staff had to take on the extra work without a handover leaving them unable to proactively check on the status of all their patients.
However, by the time the daughter was approved as a live donor in December, her mother was no longer a suitable transplant candidate because of ill health.
She died in 2014.
Hill said he believed the woman's care was compromised by numerous errors, failures to follow procedure and lack of clarity within Waikato DHB.
He said there was almost six months between the patient's last test and her presentation to the Transplant Group and "multiple missed opportunities for Waikato District Health Board to minimise this delay".
He said the daughter's evaluation as a living donor was "also unreasonably protracted".
He was also critical of Auckland District Health Board for not providing greater clarity regarding what cardiac assessments were needed and of delays in communication.
"Auckland DHB's role was one of guidance in this case, and there were a number of missed opportunities for it to provide greater leadership and clarity," he said.
Neither of the two DHBs took the lead to resolve whether the woman should have a cardiac MRI and to progress her case.
Hill made a number of recommendations, including that the three DHBs work together to review their system for sharing information, and that they develop an agreed policy around renal transplants.
He recommended Waikato DHB establish guidelines for evaluating living donors, review staffing and provide a written apology to the woman's family.
Hill also recommended Auckland DHB establish a system to provide clear instructions about what was needed for donor recipient evaluation in cases that deviate from the norm.
