The Coroner wants the Canterbury District Health Board to publicise the details around the death of a patient to avoid a repeat.
Bonnie Schlef died in February 2013, following a mistake in surgery where an artery in her brain was torn.
Coroner David Crerar wants the CDHB to continue with research into its procedures, and publicise its findings widely within the surgical community to ensure it doesn't happen again.
Neurologist Dr Andrew Laing admitted and apologised for his mistake that led to the 55-year-old's death.
Coroner Crerar acknowledged his apology, saying that's all that could be required of him.
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