A registered nurse faces possible legal action over care described as unkind and unprofessional.
Deputy Health and Disability Commissioner Theo Baker says the poor care from an unnamed nurse happened at a public hospital in April last year.
Ms Baker says the patient, who had motor neurone disease, had difficulty swallowing and needed intravenous rather than oral paracetamol.
But the nurse administered an oral elixir anyway, so the patient felt as if she was choking.
After giving the drug intravenously later, the nurse threw the empty syringe on the bed before walking away.
Ms Baker says the behaviour was unkind, unprofessional and showed a lack of respect.