A caregiver and the residential home he worked for have been found to have breached the rights of a disabled man who died in their care.
A report by the Deputy Health and Disability Commissioner Rose Wall was released this afternoon.
In it Ms Wall said Creative Abilities and the caregiver, known only as Mr C, failed to provide the appropriate standard of services to the man.
He died in late 2013 after the caregiver failed to put a pillow behind his head and shoulders after transferring him out of a wheelchair and into bed.
The man, referred to in the report as Mr A, suffered from acute obstructive sleep apnoea, cerebral palsy and epilepsy.
He was found struggling to breathe by Mr C who had gone to the ensuite bathroom to wet a flannel.
Despite attempting CPR and calling 111, the man died.
Ms Wall found the caregiver had failed to comply with the man's night time care plan by not attaching a harness after putting him in his wheelchair, and not putting the pillow behind him when transferring him back to bed.
"The man had complex needs and it was important that his care plans contained up-to-date and detailed information for staff to refer to. This was particularly important as several different caregivers provided care to the man."
Ms Wall recommended the caregiver and Creative Abilities apologise to the man's family and that the care home conduct an internal audit of its patient plans and review the adequacy of its staff training programme.