Staff in the critical care ward of a hospital have been faulted for failing to detect quickly that a patient had suffered a cardiac arrest.
The Health and Disability Commissioner has found the Southern District Health Board in breach of the Code of Health and of Disability Service Consumers' Rights.
In 2011, a woman who can not be named was taken off continuous monitoring in the hospital ward.
Five days later, she was found to have had a cardiac arrest, and died two days later.
Commissioner Anthony Hill said the woman was not monitored adequately and, as a result, her cardiac arrest was not noticed immediately.
Mr Hill recommended that the DHB review its guidelines for the critical care unit.