A resthome and several nurses have been roundly criticised for failing to give an elderly patient the medicine she was meant to have after a stay in hospital.
The unnamed resthome and its staff are faulted in a decision from Deputy Health and Disability Commissioner Rae Lamb.
The 89-year-old woman was transferred from hospital to the rest home last year with a prescription for the anticoagulant, warfarin, to help reduce her much-higher-than-normal risk of stroke.
But the resthome did not give her the medicine as prescribed for two days, despite the woman's daughter raising concerns about this with its manager several times.
Three days later, the woman collapsed after suffering a stroke. She died in hospital two weeks later of pneumonia, although no post-mortem was carried out.
Ms Lamb says the prescription was clear, and nurses failed to follow it or get it clarified quickly.