Gore Hospital has been recommended to review its procedures after a woman with a heart condition was misdiagnosed with pulled muscles and died a week after.

Susan Robinson, 50, went to the hospital in April 2009 complaining of chest pains and was told she had pulled muscles and was sent away with pain relief.

She was found dead eight days later by her mother, the Southland Times reported.

Despite further trips to the hospital as well as to her doctor, Andrew Costello, her condition remained undiagnosed.

In a report released yesterday, Southland-Otago coroner David Crerar the visits should have "resulted in a better outcome".

He said the actions of the hospital doctor who treated her, Dr John Grant, were "reasonable but incorrect".

"It is regrettable that this (cardiac problem) was not diagnosed and treated on her first presentation, although I acknowledge the difficulty in such diagnosis," Mr Crerar said.

Gore Hospital chief executive Karl Metzler said an independent review of internal procedures has been carried out and steps already taken to ensure greater patient safety.

Mr Crerar recommended the hospital review its protocols to ensure clinical errors identified in the review did not happen again, and review the operation of its ECG machine to ensure it was to an appropriate standard.

He also called on the hospital to look at ensuring patients with pain that could be of cardiac original undergo a stress test within 72 hours.

- NZPA