A man died after being dumped in a bus shelter by Canterbury District Health Board security staff because a doctor caring for him believed he was "looking for a free ride".
The Health and Disability Commission has found the DHB in breach for failing to respect the man's dignity and take his concerns seriously.
In the report the man has not been named but previous stories written by the Herald identify him as Neil David Jones, who died in October 2013 at the age of 47.
Nurses and security staff both challenged the doctor, saying Jones was clearly too ill and had nowhere to live, but were told to remove him from the hospital.
Two days later he was dead.
At the time, his family spoke out saying his treatment was "disgusting".
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In the report, Health and Disability Commissioner Anthony Hill slammed the DHB for the inappropriate discharge as Jones was clearly unwell.
Hill said he was concerned about a lack of effective response to the man's need for help, and commented on the need for staff to think critically and recognise when a patient's condition indicates that staff need to speak up and advocate for the patient.
Jones was admitted to Christchurch Public Hospital on October 8, 2013, severely jaundiced and unwell because of a long alcohol dependency.
The Herald has previously spoken to the family, who opened up about him starting to drink heavily in 2008 after his partner, with whom he had two children, took her own life.
He had been drinking three litres of vodka a day up until the time he was admitted to hospital.
After three weeks in hospital, Jones was discharged, despite remaining unwell, requiring ongoing medications and having no suitable accommodation arrangements in place.
The man was escorted from the hospital by security staff and taken to a nearby bus stop while wearing hospital pyjamas, the HDC report said.
He remained at the bus stop for many hours. Members of the public and security staff raised concerns about his condition, but he was not reassessed. Later in the day, the police were called to remove him.
He was issued a trespass notice and taken to the social service agency. While there his condition deteriorated further and he was returned to the hospital, where he died two days later.
As a result of the HDC investigation, Hill recommended the DHB apologise to the family.
He also advised them to audit the operation of its new trespass policy and review the Gastroenterology Department staff's ability to access test results, and develop a protocol for the readmission of patients who re-present following discharge.
In response to the investigation, Canterbury DHB said it accepted the breach and the recommendations outlined by the commissioner.
"I am truly sorry about [Jones'] death and for the events around his discharge," the doctor at fault said in the report.