The Deputy Health and Disability Commissioner says more could have been done for a 70-year-old man who died in a resthome of a bowel obstruction.
Theo Baker's report on the 2009 case says the man was clearly unwell, but the resthome's clinical co-ordinator, a nurse, went to a meeting instead of checking him properly.
In a report released on Monday, she found the unnamed resthome breached patient rights by failing to properly assess an unwell elderly resident who later died.
Ms Baker said ensuring proper care for the man should have been the top priority of the clinical coordinator.
The man became unwell with abdominal pain at the privately-owned resthome in 2009.
Staff were alerted and the clinical coordinator, a nurse, told a caregiver to check and let her know if he deteriorated while she was away.
The man was taken to see a doctor later that day, but deteriorated rapidly and died before an ambulance could arrive.
The clinical coordinator complained that she was over-worked and under-supported, but Ms Baker says she should have known that the man was seriously unwell and done more.
Ms Baker told Checkpoint the care was not all it should have been, saying if the nurse could not check the man, she should have left explicit instructions with the nurse aide monitoring him in her absence.