The Health and Disability Commissioner has found a brain injury rehabilitation centre failed to adequately care for a man who died there in 2011 after a seizure.
Staff at the centre did not check on the man for nine hours following the seizure and eventually found him dead in his room.
In 1995, the man suffered a traumatic brain injury and developed post-traumatic epilepsy which caused seizures. Following a further brain injury in 2003, he became a resident of the ABI Rehabilitation Service.
The man was described as difficult to manage, refusing to take medication and displaying aggressive behaviour.
As a consequence, the medication was administered surreptitiously by crushing it and giving it to him through food and drink.
Commissioner Anthony Hill found that the rehabilitation service failed the man in several ways, including through a lack of a cohesive approach to his care.
Mr Hill said the documentation of the man's seizure activity was below standard and staff members failed to ensure that recommended tests and medical reviews were carried out.