An elderly woman died in hospital within a fortnight of receiving inadequate care for an infection at a Christchurch resthome.
Deputy Health and Disability Commissioner Theo Baker said in a report released on Monday that Middlepark Rest Home and Village in Riccarton and several staff breached patient rights over the case.
The woman in her 80s developed a urinary tract infection at Middlepark in 2011, but tests were not done to confirm it and she was given only half of the antibiotic course needed to treat it, Ms Baker's report said.
She deteriorated and fell several times - but the falls were not recorded, nor the family told. The woman was also treated palliatively, and this had also not been been discussed with her family.
The woman was sent to hospital after a daughter insisted, but died soon after of an infection originating from the urinary tract infection.
Ms Baker said systemic failures by the resthome caused unnecessary distress and delayed treatment, and the woman's health was not a high enough priority for it.
"It seems as though there were some staff doing their job, but not communicating with others. There was very poor continuity of care and it's an example of not having the patient at the centre of services."
Meanwhile, the owner of resthome on Monday mistakenly released woman's name. Oceania Group made the slip-up in a statement responding the deputy commissioner's findings but retracted it when Radio New Zealand questioned that action.
The resthome said staff were under pressure, but that was no excuse for poor care and changes have been made.
