Care failures by an Auckland aged care provider ended with a woman dying of blood poisioning in a public hospital.
A report released on Monday said the woman, in her late 40s, died after pressure sores became badly infected in 2010.
Deputy Health and Disability Commissioner Theo Baker said the woman was admitted to the Radius St Joans Hospital in Auckland following a stroke.
The report said she was morbidly obese and at high risk of pressure ulcers, but nothing was done to prevent them.
She developed a deep and painful sore that failed to heal, and was admitted to hospital with a fever and organ failure.
It was decided she would not survive an operation. She instead received palliative care and died two days later of blood poisoning from the ulcer.
Ms Baker said two clinical managers failed to prevent or manage the ulcers and to monitor her worsening condition.
"It's actually basic nursing care and it's really the standard of care that anyone would be expected to receive if they were in that circumstance. It's very concerning that these pressure wounds developed to the extent that they did, in a relatively short period of time, leading to a significant infection."