A coroner is calling for Canterbury DHB to review its procedures - after a man suffered a heart attack on a West Coast farm

Bryan Edmonds, who had a family history of cardiac death and a prior heart murmur - had been admitted to Christchurch Hospital in the year before his death - but no follow up was carried out..

The DHB says a clerical error meant he was wrongly put down as a patient of the Bulls Medical Centre instead of Buller Medical Practice..

Edmonds was also seen by a doctor on the West Coast in the months before his death - when he complained of black outs.

A chest X-ray and follow up was ordered but there was no record of it being done.

Coroner David Robinson says it would be purely speculative to say if a cardiology referral or follow up would have prevented the death..

However, he says the fact the DHB could not provide a copy of Edmonds discharge summary showed evidence of a lack of continuity of care..

He recommended the DHB review procedures for identifying medical practices where patients are and to ensure all files for patients are sent to the right GP.