Southland Hospital in Invercargill has been told it breached the patient rights code over the care of an elderly man three years ago.
The Health and Disability Commissioner on Thursday reported on the case of the unnamed 82-year-old.
Ron Paterson says the man wasn't reviewed in person by a senior medical officer at Southland until three days after his arrival from Gore Hospital.
He says the hand-over between teams at Southland was poor, the man received too much fluid, and, when his condition deteriorated, he didn't get prompt and appropriate response.
The man later died in Dunedin Hospital.