Staff at an unnamed resthome have been taken to task after a 90-year-old woman died following poor care to post-surgery wounds.
Deputy Health and Disability Commissioner Rose Wall has criticised two unnamed registered nurses for failing to provide appropriate care for the woman, who had developed serious blood poisoning after surgery.
The woman was discharged to the resthome from a public hospital after the removal of cancerous sections of skin in 2012.
But the hospital level care ordered by the doctors did not eventuate, her wounds became infected, and her condition deteriorated over the next 10 weeks.
She was re-admitted to the public hospital and diagnosed with overwhelming sepsis and pneumonia, and died soon afterwards.
Ms Wall said the resthome failed the formerly lucid and alert woman and should have had a wound-care plan in place.
"They should have been monitoring for signs of infection, so looking for inflammation, infection in terms of temperature, general unwellness, in terms of how the woman was presenting, whether there was pain, whether there was discharge from the wound, all those sorts of things.
"And there should have been actions taken sooner, in terms of responding to signs of infection."