A Coroner says an Otaki resthome caused the death of a 96-year-old woman, who died after being given the wrong medication.
Margaret Borgen, a resident at the Ocean View Rest Home, died in Palmerston North Hospital in May last year after being given blood pressure drugs prescribed for another resident.
Hastings Coroner Christopher Devonport said staff at the resthome did not follow correct procedures.
An ambulance was not called for close to three hours after Mrs Borgen was given the wrong medication.
The clinical manager of the hospital's Emergency Department said had Mrs Borgen arrived sooner, there would have been a significantly better chance of her surviving.
An earlier Ministry of Health audit concluded that the resthome needed to improve its management of medicines.
The home's manager, Roselle Kymbrekos, has refused to comment on Thursday.
Grey Power vice-president for the Kapiti Coast, Trevor Daniel, believes the death is further evidence of underfunding in the aged care sector.
"The government funding doesn't allow, I don't believe, for adequate training of the carers who look after people in these homes."
The New Zealand Nurses Organisation noted the accident happened because a staff member was distracted by other tasks while giving medication and wants legislation introduced to mandate minimum staffing levels.