Whanganui District Health Board and several of its nurses are being told to apologise to the family of an 80-year-old woman who died following failures in their treatment of her injured foot.

A report released by the Health and Disability Commissioner Anthony Hill found the DHB and two of its nurses were in breach of the Code of Health and Disability Services Consumers' Rights for their dealings with the case.

The DHB breached the code by failing to ensure individual clinicians involved in referring the woman had all patient information.

Breaches also related to failings to follow up an urgent referral for vascular assessment and not documenting pain and escalating care when the patient's condition deteriorated.

The woman was 80 years old when she injured her right foot and first visited her GP in March 2015.

She was referred to Whanganui Hospital for an assessment by her GP, however an orthopaedic surgeon at the hospital was unable to read the referral.

The surgeon therefore did not triage the referral and the woman went back to her GP, who referred her on to a podiatrist for an urgent assessment.

Her case was passed on to the district nursing service for care of the wound, and back to the hospital for further assessment. Later that month a surgical consultant at the hospital triaged the referral as semi-urgent.

District nurses who visited the woman during March and April noted the wound was very painful and requested a specialist assess the wound.

However when the specialist said the patient needed urgent vascular assessment, a consultant at the hospital was not made aware of the multiple other referrals.