The family of a Christchurch woman who died after being given medicine she was allergic to is pleased the DHB has learnt from the tragedy

80-year-old Eunice Richardson died after a nurse and registrar failed to check warnings on her MedicAlert bracelet, and was prescribed treatment that caused an allergic reaction.

The Health and Disability Commissioner found their systems weren't up to scratch, and there was no excuse for the woman's allergies to go unnoted by both staff members.

Her husband Lawire said the CDHB has taken onboard the recommendations, including routine checking of MedicAlert bracelets.

"That's the big one," he said. "My wife was wearing one and no one checked it. At least something is coming out of it."

Richardson said it had been hard trying to move on, but the report may help bring closure.

"This has been dragging on, I've been drip-fed bits, progress reports, and they just bring it all back again."

The Health and Disability Commissioner said the accident was a severe departure from acceptable medical standards, and CDHB Chief Medical Officer Nigel Millar agreed there were gaps in the process, but he's confident an electronic system will stop it happening again

"There's no paper involved now, and that means you can have a much more structured approach to recording drugs to which people are allergic and then if somebody sets out to describe them, they're at least going to be clearly warned."

Millar said that small mistake had massive consequences and that's what they want to avoid in future.

"You always have this fear that you'll have one lapse or you'll forget something or miss something and sadly that's what's happened. We need to make it much harder for the small human failings that occur along the way to cause such an outcome."

The Commissioner recommended the Medical and Nursing Council's of New Zealand review the competency of the staff involved.