After almost three weeks in hospital alcoholic Neil David Jones was dumped in a bus shelter by security staff because the doctor caring for him believed he was "looking for a free ride".
Nurses and security both challenged the doctor saying he was clearly too ill and had nowhere to live, but were told to remove him from the hospital.
Two days later the 47-year-old was dead.
Today, the hospital is among one of several agencies to be severely criticised by the coroner following an report into the Christchurch man's death.
Key criticisms include:
• The decision not to continue to monitor him despite concerns being raised about his health.
• The fact he was not reassessed when he was brought back to the hospital after reports of concern from members of the public who saw him lying at the bus stop.
• The lack of initiative shown by police in questioning the hospital's request to have Jones removed.
• The two to three month delay in finding space for Jones in a residential rehabilitation centre.
Canterbury District Health Board chief executive David Meates admitted the report made "sobering reading" and that the system failed Jones.
He had personally apologised to Jones' family for the failings in his care, he said.
"Unfortunately it's only recently that the full extent of the failures in our treatment and care of Mr Jones have come to light, and the Coroner's report makes sobering reading," he said in a statement.
"This report has caused us to look long and hard at what happened in October 2013 and reflect on what's changed over the past four years.
"I am satisfied that the extent of changes made are such that our improved systems and processes would not allow a repeat of the unfortunate chain of events."
The changes included not discharging a patient unless they had suitable accommodation; the Speak Up training programme where all staff were encouraged to raise concerns; the ability for staff to elevate concerns to a duty nurse manager who will get the patient reassessed; approval of the hospital general manager before a patient can be trespassed; and improved waiting times for residential treatment programmes.
Meates said it was not appropriate to single out any individual staff member or team. "The buck stops with me as chief executive. Our systems at that time didn't support staff to do the right thing, and for that I apologise."
A police spokesperson said they acknowledged the coroner's findings but the decisions made at the time were based on the information provided to officers at the hospital.
"Police continue to work with partner agencies and are focused on responding to demand."
Jones was admitted to Christchurch Public Hospital on October 8, 2013 severely jaundiced and unwell because of a long alcohol dependency.
He began drinking heavily in 2008 after his partner, with whom he had two children, took her own life.
He had been drinking 3L of vodka a day up until he was admitted to hospital.
Jones' parents in Nelson were looking after the children and had him trespassed because of his addiction at one stage, but since then he had stayed with them while visiting his children.
After his death, his parents said they had not been contacted and informed of his situation but would have provided him with accommodation had they been asked.
He had been living with his new partner Elizabeth Wells since 2012. Jones had sought help but he and Wells had been told there would be no space for him in the city's residential rehabilitation programme until December.
Jones wanted to stop drinking, Wells said, but was unable to on his own.
By the time Jones was hospitalised she could no longer cope with his alcoholism so sent his clothes and a trespass notice to him in hospital.
Jones suffered from vomiting, ate poorly and slept a lot. He appeared muddled in his conversation and was unable to follow instructions at times.
But almost three weeks after he was admitted duty consultant gastroenterologist Dr Richard Gearry decided his health had stabilised so decided to discharge Jones despite having nowhere to live and nurses and security staff raising concerns.
Nurses reported he was muddled in his communication, had defecated in his own clothing on the morning he was to be discharged, had been walking around the ward with net underpants on and remained jaundiced.
Security guard Nigel McFall said he was fumbling around, slurring his words and appeared really sick.
McFall said Gearry told him tests were fine and that he was pretty much just "looking for a free ride".
Despite this, Gearry, who had taken over his care for the weekend, ordered Jones' discharge believing he had deliberately defecated in his clothes so he could stay in hospital.
Gearry told the coroner, with the benefit of hindsight, it was not in Jones' best interests to be discharged, but when he spoke to Jones he did not show signs of confusion or distress. It had been reported to him Jones was deliberately incontinent, he said.
During the day numerous members of the public contacted the hospital raising concerns about him lying beside the bus stop looking unwell. They feared he would be injured where he lay.
Hospital staff told them he had been medically cleared and was fine.
In the afternoon an orderly brought Jones to the emergency department but he was not treated or further assessed.
Police were called to remove Jones from the hospital. They trespassed him and drove him to the Christchurch City Mission which reluctantly agreed to assess him with the proviso if he was deemed unfit to stay the police would collect him and take him back to the hospital or a psychiatric service.
The mission decided he was obviously unwell so called police to pick him up.
Two hours later police had not arrived and Jones started vomiting blood so an ambulance was called.
He was readmitted to the hospital and died less than two days later.
Christchurch City Missioner Matthew Mark said he was surprised Jones was discharged, trespassed and brought to the mission because, as the report pointed out, it was obvious what a dire state he was in.
He said it was a cause for concern but he was hopeful the changes made by the DHB would prevent the same issue in future.
Coroner Michael Robb ruled Jones' death was caused by alcoholic liver disease, but said "his discharge resulting lack of medical evaluation and treatment, coupled with what took place for Neil throughout 28 October until he was readmitted to hospital that night, may not have caused his death but did not enhance his chances of survival".
Robb criticised Gearry's decision saying the direct contact he had with Jones while he was awake was limited and brief and that with Jones' known medical condition it was entirely plausible deterioration in his health was the cause of his behaviour.
Clinical notes highlighted genuine concerns so, at best, the situation was unclear, the coroner said. The safer course of action would have been to wait until results came back from a blood test taken on October 25 and to keep monitoring him. Gearry said he was not aware a blood test had been undertaken.
Robb also criticised Canterbury District Health Board's processes.
The decision to enforce Jones' discharge was aggravated by the fact no one made an appropriate medical assessment of him later that day despite multiple members of the public raising their concern with the hospital, he said.
"The picture of Neil being very unwell and observed by multiple members of the public lying on the ground outside the hospital was an appalling one."
Regardless of the doctors earlier determination, process should have been followed and he should have been assessed when he was brought back into the emergency department, he said.
The police undertook "limited, if any, investigation of the circumstances and were certainly not in a position to determine that questioning the trespass decision or pursuing concern over Neil's obvious ill health would be fruitless", Robb said.
The police did not evaluate the circumstances; consider or investigate how long Jones had been lying outside the hospital; investigate why he was "a nuisance" to hospital staff and the public; or establish when he was last medically assessed.
For police to have a demonstrably unwell man in their patrol car did not "represent initiative and good policing", he said.
Robb also said the two to three month delay in finding space for a voluntary admission to an alcohol treatment programme was "wholly inappropriate" .
Not only was it frustrating for the individual but caused aggravation of the disease, he said. "Had there been access to rehabilitation in August, when he was assessed as requiring that rehabilitation, he may have been successfully treated and alive today."
The treatment and care of Jones was still the subject of a Health and Disability Commission complaint.