An inquiry has found a man who died in hospital spent almost two weeks in the wards without enough food and water.
Doctors, nurses and managers have been criticised for not doing enough to care for the 89-year-old, who died after having a hip operation.
The man was first taken to an emergency department of Waitemata District Health Board (DHB) by ambulance after falling on a footpath during one of his regular walks.
He arrived with a history of poor health, including Type 2 diabetes and heart disease.
He was found to have a hip fracture, but doctors decided to deal with his other medical problems before performing a hip operation.
Health and Disability Commissioner Anthony Hill said throughout the man's 15-day stay at the hospital he spent time in four different wards.
"He complained of hip pain frequently, and was vomiting. A range of oral and intravenous medications was given to alleviate his pain, minimise his confusion and reduce his vomiting. However, often he refused oral medications, and sometimes the intravenous line did not work properly.
"The man also frequently refused food and drink."
He was also, at times confused and delirious. One day, he was restless and was yelling and tried to get out of his bed.
The commissioner's report details that the man was trying to pull fluid lines from this body.
On the ninth day of the patient's stay in hospital, he underwent hip surgery which went well. But he was still refusing food and drink.
Mr Hill was alarmed to find out that it took 13 days for a dietician to be called in.
"I am concerned that a dietician referral did not occur until Day 13, when the physiotherapist made the referral. By this time, Mr A [the patient] had been in hospital for 13 days without adequate oral intake."
Waitemata DHB said the patient should have received regular nutritional assessments through his admission. It was found that he was clinically dehydrated.
A clinical record stated the malnutrition universal screening tool should have been completed within the first three days of a hospital stay, but it was not. In addition, no food diary was started.
The 89-year-old died on his fifteenth day in hospital. His family called the hospital early that morning to be told he was resting. But later, at 8am, a nurse found him cold and unresponsive.
Mr Hill said:
"Critical thinking was lacking, in particular, the evaluation of his pain, and the management of his oral care, fluids and nutrition.
"In addition, my expert nursing advisor, Ms Dawn Carey, advised that, in her opinion, the four wards operated as 'information silos'. I am also concerned that within Mr A's clinical notes there are blank assessments, and inadequate or blank care plans, and clinical requests have been made but not actioned."
Ms Carey went on to say: "In my opinion, it is simply not sufficient to continually report a 'problem' without attempting to clinically manage it."
She noted there was a lack of nutritional intervention or management by the nursing staff.
Mr Hill said he was now satisfied that, since the case, Waitemata DHB had put in place a number of new initiatives to ensure better care was provided in similar situations in the future.
The DHB has been asked to apologise to the man's family.
