A rest home resident was rushed to hospital where a nurse found maggots in infected leg and foot wounds that would kill the 71-year-old soon afterwards.

Deputy Health and Disability Commissioner Rose Wall released a report on the distressing case today, noting the woman's painful wounds "were allowed to progress to such a degree that they were significantly infected and some had maggots".

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The woman had serious underlying conditions including vascular disease, heart failure and diabetes, and had previously had a below-knee amputation of her left leg.

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After about six months in the central Auckland rest home she became unresponsive and an ambulance took her to hospital. The next day, a nurse found the wound around the left stump was seeping and had maggots, and four large maggots were also washed out of wounds on her right foot. Her toes had dying tissue.

A short time later the woman died from sepsis secondary to her infected ulcers.

At the time, the rest home was run by Care Alliance Limited. In March 2017 it was sold to new owners unrelated to the company. A facility manager told the Herald it was now a completely new regime, with new staff, management and ownership.

When the Health and Disability Commissioner (HDC) contacted Care Alliance, its director said he didn't have any information "because he no longer had possession of his laptop where the information was stored, nor was the information stored elsewhere".

According to Companies Office records, the director of Care Alliance Limited is David Schwartzshtein. The Herald has sought to contact him, including via another aged care company he still operates.

The woman had been sent to the rest home after a hospital stay, because she needed long-term, hospital-level care. Her complex health needs meant she was likely to develop wounds, and had existing ulcers when put under the rest home's care. Once there, she developed new wounds that weren't properly cared for.

Her daughter complained to the HDC, which has recommended Care Alliance Limited provide her with a written apology, and that the rest home's current owners show evidence of how things have improved at the 52-bed facility.

Rest home notes from the time of the woman's care record "an excessive number of flies in the building", and maggots had been recorded in her wounds on two separate occasions.

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The facility told the HDC that the notes and recollections of health workers who had attended her - including nurses, GPs and an external wound care specialist - didn't show any deterioration of wounds before she was taken to hospital.

"The rest home stated that Ms A's ulcers were present when she was first admitted to the rest home, and fluctuated in severity during her time there, but had been stable for months," Wall noted in her HDC report.

"I note that Ms A's wounds were chronic, and that she had conditions that limited their ability to heal, and that she is noted to have been regularly non-compliant with recommended treatment and wound dressings.

"However, I am highly critical that the communication and cooperation between staff about Ms A's wounds was inadequate, and that staff failed to seek GP consultation adequately."

The woman was in considerable pain, Wall found, but there wasn't evidence of any pain relief given prior to dressing her wounds, and no specific care plan in place to manage pain levels.

The horrifying case will intensify calls by Grey Power and others for the Government to reform the sector, and set up an Aged Care Commissioner, which Labour and the Green Party campaigned on, but have so far failed to take action on.

Associate Health Minister Jenny Salesa received preliminary advice from officials on setting up an aged-care commissioner over a year ago. That is still under consideration, she recently told the Herald, and a number of changes were being made to better protect rest home residents.

The aged care sector is expanding rapidly as the population ages. There are about 83,000 New Zealanders aged 85 or older, a number forecast to rise to up to 284,000 by 2043 and 467,000 by 2068.

Last year a Herald investigation reviewed more than 1000 audit reports for the country's aged care facilities, and found that since 2016 a third had shortfalls related to resident care. Almost 100 facilities had shortfalls in wound care.

In 2018 a rest home resident in South Auckland had about 15 maggots hatch in his wounds after dressings weren't apparently changed frequently enough.