An elderly woman with breast cancer who went into surgery for a mastectomy- died from a brain injury after a breathing tube was mistakenly put into her oesophagus

Health New Zealand described the death as a perfect storm - as the 73-year-old had experienced difficulty with a breathing tube and surgery before - and the staff operating on her assumed she was having a similar problem.

Open Justice reports Deputy Health and Disability Commissioner Carolyn Cooper found both Health New Zealand and one of the doctors involved breached patient rights.

She's ordered her report be sent to the Medical Council, while Health NZ says it has made multiple changes since - including updating crisis checklists and reviewing team training.