A rest home resident had about 15 maggots hatch in his wounds after dressings weren't apparently changed frequently enough.
Counties Manukau DHB investigators found a lack of documentation around how often staff at Palms Lifecare in Pukekohe changed the 86-year-old's dressings. There was a gap of seven days in one instance.
The man's family have now released the investigation report to the Herald, in an effort to stop other aged-care residents suffering.
He was moved from Middlemore Hospital to the rest home as a terminal resident needing palliative care, and died on March 9, soon after his daughter went public with her concerns.
The DHB investigation substantiated shortfalls including inadequate pain relief, anecdotal evidence of faecal soiling in his room and a lack of neurological assessments after falls.
"There is limited documentary evidence that the resident's wounds were dressed during the timeframe for the fly eggs to hatch, which meant the eggs could fully develop into maggots without being disrupted," the DHB report concluded.
Dressings were meant to happen every other day, but were documented on February 6, 8, 11, 18, 19, 25 and 28. A maggot can hatch within a day.
On February 28 an entry in the man's file states the dressing needed reviewing in two days, but there wasn't further documentation until March 4 – two days before the maggots were found.
Seven to 10 were removed from his big toe. Progress notes indicate that later that day another four to five were removed. The next day another maggot was found.
The man's daughter Corina, who asked for her surname to be withheld, said learning of other care problems when reading the DHB report was deeply distressing.
She met with the DHB this week and asked it to revisit aspects of her family's complaints that weren't fully substantiated. That includes the belief their father rapidly declined in health and suffered a stroke, which wasn't addressed by staff.
"We knew he was going to die … but I did expect them to give him the basics of life – food, fluids, being kept clean and pain relief," Corina said.
The family has received an apology from Heritage Lifecare, the company that owns Palms and 25 other rest homes.
A spokeswoman for the company said existing procedures weren't followed and appropriate disciplinary action had taken place.
"The company obviously deeply regrets the incident that took place but is confident - and this is supported by the DHB independent review - that such an incident does not occur again."
Executive chairman and founder David Renwick said in a statement: "We take the finding of these investigations extremely seriously and have reinforced to all staff at Palms and throughout the wider group the need to adhere to existing and proven procedures to deliver the very best care, in line with Heritage Lifecare's standards."
Counties Manukau DHB is confident residents at the 120-bed Palms are safe, and says it will keep working with Palms to "ensure an appropriate level of care".
The horror case comes after a Herald review of more than 1000 audit reports for the country's 651 facilities since 2016 found more than a third had significant shortfalls related to resident care.
Consumer NZ believes the Palms Lifecare case shows the auditing system is inadequate and needs to be strengthened – the facility's latest audit resulted in no corrective actions.