The Health and Disability Commissioner has found poor care at a resthome probably contributed to an elderly woman's death.
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A report from the commissioner said the woman died in 2016 after living at the Aria Park Retirement Village in Auckland for six years.
In 2016, the woman had a fall but her family was not told and no incident report was filled out.
She fell a second time after two caregivers used the wrong equipment to transport her.
A doctor recommended the woman go to hospital, but an ambulance was not called for three hours.
It was later found she had a broken elbow, pelvic fractures and an injured shoulder.
When she returned to the resthome, staff failed to give her pain relief.
She was eventually taken back to hospital where her condition deteriorated and she died.
Three people were dismissed as a result of the incident, and the commissioner recommended Aria Park apologise to the woman's family.
The commissioner also recommended Aria Park use the report as a case study to teach staff, and report back in three months detailing what improvements it has made.
