A woman receiving palliative care at an Oamaru rest home was in so much agony her daughter felt she needed to bring additional pain medication from home, a report says.
Deputy Health and Disability Commissioner Rose Wall today released a report in which she slams two nurses for not alerting staff or doctors that non-prescribed medicine was being given.
The 57-year-old patient had advanced pancreatic cancer and was in severe pain multiple times within four days leading up to her death in 2013.
Ms Wall said during this time no one at the Rendell on Reed rest home performed a pain assessment and her vital signs were not checked.
She recommended the nursing council check to see if there should be a competency review of the two nurses involved.