The Counties Manukau District Health Board made mistakes in its relationship with the Muliaga family, the report says.
It did not criticise the level of care the board gave Folole Muliaga, but did criticise communication and documentation failings.
The family say they were not aware how serious MrsMuliaga's condition was, and did not know she was classified as "not for resuscitation".
The board's chief medical officer, Dr Don Mackie, told the Herald yesterday that he had no way of knowing whether the non-resuscitation order was discussed with Mrs Muliaga.
The "not for resuscitation" classification was medically appropriate, he said, but the board's policy demanded such a decision be discussed with the patient.
Whether it was discussed was not clear because the relevant documentation was absent. Without it, Dr Mackie had no way of saying if that communication had taken place.
The health board had accepted that was "not good enough" and was adopting all recommendations in the coroner's report to ensure the mistake was not repeated, Dr Mackie said.
Changes included giving patients and their families educational material about resuscitation policies, and refresher courses for staff on documentation requirements and Not for Resuscitation policies.
Hospital discharge summaries were being reviewed to make sure patients understood them better, and a patient and family information pamphlet on obesity hypoventilation syndrome was being introduced.
