The Waitemata District Health Board and a nurse failed to provide adequate care for a dementia patient, the public health watchdog says.
The details are released in a report today by Deputy Health and Disability Commissioner Theo Baker. The nurse has not been named.
The 87-year-old man was admitted to hospital after a fall, and had another in hospital. Despite this, neurological investigations were discontinued and staff also gave drugs, including aspirin, that the man had stopped taking, Ms Baker said.
Deteriorating behaviour, including aggressiveness and wandering, meant the man was put on 15-minute checks in a locked ward.
However, checks were missed and he left hospital and was not located for two-and-a-half hours, Ms Baker said.
"One would have thought that, this gentleman should have been seen at 5.45 and at 6 o'clock that at the time the nurse went to have his tea break at 6 o'clock he would have ensured that the check was done at least then. And in fact, no one tried to look for him again until 7 o'clock."
Tests after the patient's return revealed a serious brain bleed, probably from a fall, and he died several days later.
Better monitoring was needed for a patient whose behaviour was clearly worsening, Ms Baker said, and the DHB failed to follow standard procedures for neurological investigations.
"You add to that a son who's saying, 'Actually, this is not normal behaviour. Yes, he's been getting a bit forgetful lately, but he's really behaving unusually now'. And yet still that wasn't followed up on properly."