The death of the patient, age and gender unknown, was caused by a blood infection as a result of peritonitis (inflammation in the abdomen) following a delay in carers recognising a bowel perforation.
The patient had been in a palliative condition and had "not received optimum care".
Bay of Plenty District Health Board chief executive Phil Cammish said it would not be releasing any further information about the patient who died.
"The BOPDHB has been fully engaged with the family throughout the investigation process. They have requested that no further information be released relating to this case and out of respect for that wish we will not be doing so."
Of the falls, two patients suffered brain bleeds including one being acute, five broke their hips or shoulder and one dislocated their hip and needed surgery.
Mr Cammish said the recording of such serious adverse events (SAEs) was about learning when things go wrong during the provision of healthcare, being open about that and doing everything they could to prevent similar incidents happening in the future.
"The Bay of Plenty District Health Board takes this responsibility very seriously and has an ongoing focus on reducing the number of SAEs, as our record indicates."
Nationally, the commission reported a four per cent increase in serious adverse events, but the nine recorded this year in the Bay was three fewer than in 2012/13.
This represented a 25 per cent decrease, Mr Cammish said.
The commission also reported the district health board recorded the lowest rate of serious adverse events per 100,000 bed days of any of New Zealand's 20 district health boards.
"Historically, and nationally, falls form a major component of SAE numbers and this year eight of the BOPDHB's nine reportable events were falls-related. This is a continued area of emphasis. The BOPDHB has an established falls prevention programme which incorporates two falls working groups (one looking at organisational reportable events and the other monitoring what is happening nationally, regionally and locally with regard to falls prevention).
"This programme is continually monitored and reviewed to ensure best practice is applied to reduce harm from falls."
