A rest home has been criticised for its failure to provide basic care to a man who was found with maggots on his toes.
The Health and Disability Commissioner (HDC) asked Heritage Lifecare to apologise to the man's family for having him suffer unnecessarily in his last months.
The report's findings showed the rest home and the manager in breach of the Code of Health and Disability Services Consumers' Rights.
It said the man became unwell while staying in the rest home - he fell over three times, lost weight and showered irregularly.
It said staff took too long to re-apply dressings on the wounds on his legs, and when they did, he reported pain.
It also added it took too long for him to be looked at by a doctor and podiatrist, and senior staff failed to respond adequately to a formal complaint made by his family.
Deputy Health and Disability Commissioner Rose Wall said his unnecessary suffering was unacceptable.
"[The man] was for end-of-life care, with significant co-morbidities," she said.
"His family had stressed to staff their wish that he be comfortable in his final days… [He] should not have had to rely on his family to advocate on his behalf for such a fundamental component of his end-of-life care."
She called for the Nursing Council to carry out a competence review of the manager, and recommended that the rest home owner report back to HDC on the implementation of its own action plan developed in light of this case.
Wall said she considered the number of failings by the rest home pointed to an environment that did not sufficiently assist staff to do what their job required.
Heritage Lifecare chief executive Norah Bower said changes had been made.
"The HDC identified a couple of matters that we needed to address about staffing. There was an issue suggesting that we employ additional clinical staff, and since then we've employed two unit coordinators as well, and have appointed three new registered nurses.
"We've since undergone an audit by the DHB and they have signed off on those findings."
She said they had also contacted the man's family.
"But no matter how I look at it, we owe the family an apology, and we certainly did that.
"When you're in this position, no one wants anything like poor care to happen to a resident, so we needed to make that clear to them, and assure them the changes we've put in place have identified the shortfalls the HDC have identified."