"The commission haven't minced their words about the fact there have been breaches of codes. It's good to have that confirmation," he said.
He said his father was at risk of falls, but his death could have been prevented if more had been done to avoid him toppling over or to treat him quickly once he had fallen.
"By the time someone took action, it was too late."
Deputy Health and Disability Commissioner Theo Baker's report said the Canterbury District Health Board and three nurses had breached the code of patients' rights. She recommended training for three nurses and a competence review for a fourth if she sought to resume nursing.
"I am alarmed that Mr A [Alain Closel] could lie on the floor from 3.30am until 1pm with no observations being recorded and no thorough assessment being conducted.
"At least five nurses on the day shift were aware that Mr A was on the floor. However, no one questioned his status. I am troubled [three nurses] felt that they could not escalate their concerns because of the seniority of RN [registered nurse] P."
"This appears to have been an example of dysfunctional group dynamics where the less-experienced staff felt disempowered and unable to advocate for Mr A despite their concerns about his presentation."
She said changes introduced by the DHB since the case included "Speak Up" training to help new-graduate nurses "speak out safely" if concerned about patient care.
Physically frail and experiencing bipolar disorder, Mr Closel was moved from his rest home to Hillmorton Hospital as a voluntary patient on a May Friday in 2013 after his mood became elevated. Despite his requests to be returned to the rest home, he was kept at the hospital.
He was found on the floor of his carpeted room at 3.30am on the Sunday by a nurse, who saw he was breathing at a normal rate and thought he was asleep. She put a blanket over him and, with another nurse, assessed his breathing, colour, response, position and comfort. They did not consider the possibility he had fallen. A morning-shift check by a third nurse also found no cause for concern.
About 1pm he was lifted into a chair. Soon after the 3.10pm shift handover, he was observed to be cold and pale. A doctor's assessment led to his ambulance transfer to Christchurch Hospital where, after a CT scan, a subdural bleed on the brain was diagnosed. It was considered too large to treat and Mr Closel died on the Sunday night.
Mark Closel said police investigated but no charges were laid as a successful prosecution was considered unlikely.
He understood the coroner's inquiries would now resume.
