Deputy Health and Disability Commissioner Tania Thomas says a rest home made repeated failures in its care of a sick 93-year-old woman.
Ms Thomas has found the rest home and its private hospital breached patient rights by not providing more frequent assessments and clinical observations for the woman, and better communication between staff and her family.
In a reported released on Monday, she highlighted poor communication between doctors and nurses at the unnamed facility.
The woman had lived at the rest home for more than a decade and had chronic health issues, and her death was not unexpected.
But Ms Thomas says it was the standard of care in the months leading up to her death in 2009 that was of concern.
Woman 'in pain, agitated'
"She'd had a suspected stroke, she'd lost weight, she had difficulty swallowing, she had deteriorating function and it was frequently noted that she was restless, agitated and in pain. And yet despite that, few interventions were planned, implemented or evaluated during that time.
Family members became alarmed when her health began deteriorating and she lost 4kg over five months in 2009.
They asked repeatedly to speak to her doctor, but poor communication between rest home staff and doctors contracted to provide care meant a meeting never happened.
Ms Thomas says the day the woman died, a nurse and doctor each thought the other had spoken to the family, but neither had.
"This case," Ms Thomas says, "involved nearly 10 registered nurses, and the same number of health care assistants ... and many of the shortcomings were common to a number of the staff, Now this suggests you can have all the policies in place but if people don't adhere to them, they're meaningless."
She says the rest home is ultimately responsible for widespread failures by its staff.
Ms Thomas says the rest home has since made many changes to improve its care.
She also says privacy interests in connection with the rest home outweighed the public interest in knowing its name.
Assurance from rest home association
The Aged Care Association says people can have confidence doctors and nurses know what they are doing when caring for the elderly.
Chief executive Martin Taylor says other rest homes can learn from the report.
He says overall, the sector is better off for knowing what went wrong so it can ensure the same failures don't occur in other rest homes.
Mr Taylor says rest home managers need to have procedures in place to make sure staff are communicating.