The Health and Disability Commissioner has recommended the nurse manager of a Hutt Valley resthome apologise for not ensuring an elderly woman there had adequate care.
The woman died of dehydration after seven days in the resthome.
The woman, known as Mrs A, aged 85, was discharged from a public hospital to the care of Summerset Trentham Rest Home and Hospital.
The hospital discharge summary stated that her hydration must be carefully monitored. But that did not happen and her condition deteriorated over the next seven days.
Mrs A was re-admitted to hospital where she died six days later, of dehydration and respiratory arrest.
Staff training recommended
In one of his final decisions, Commissioner Ron Patterson has recommended resthome staff undergo training in obtaining informed consent to treatment.
And he said the nurse manager should accept her failings and apologise to Mrs A's guardian.
Mr Patterson also noted a "disturbing culture" of non-compliance with clear internal policies and procedures as evidenced in several recent HDC reports involving various rest homes.