A woman in her 90s with "rotting skin" died after rest home staff delayed calling an ambulance and then told the 111 call handler she was low priority.
Today, two years after her death, the woman's family have won an apology from the rest home after the Health and Disability Commissioner (HDC) investigated the woman's last 24 hours of care.
New Zealand's health watchdog found the woman became delirious from a severe skin infection and there was a delay in calling an ambulance.
She was assigned a low priority call as rest home staff assumed she would be okay if there were more urgent cases that required ambulance care, the HDC report said.
Names of the rest home, its staff, the woman and her family were not given, citing privacy reasons.
While waiting for the ambulance, the woman's daughter arrived and discovered her mother in a lot of pain.
"I noticed a 'rotting skin' smell, and that a fly was constantly trying to land on her bandages ... one of mum's toes was a dark purple colour. When I folded the bandage back I was shocked to find all of the toes the same colour on both feet," the daughter told the HDC.
The ambulance arrived three hours later and she was rushed to hospital, where she was diagnosed with sepsis due to cellulitis, which is a skin infection, and reduced blood supply to her legs.
Sadly, she did not respond to treatment and died.
Deputy Health and Disability Commissioner Rose Wall found the rest home in breach of the Consumers' Rights (the Code) for not providing the appropriate care.
They failed to recognise and assess her sudden onset of delirium, arrange alternative pain-relief measures, and monitor her food and fluid, Wall said.
"As a result, the woman experienced unnecessary pain and suffering."
The deputy commissioner also criticised the lack of an Advance Care Plan to ensure her end-of-life wishes were taken into account.
She recommended the rest home carry out an audit of patient records for staff compliance with rest home polices and provide staff training on topics such as delirium, sepsis, escalation of care, advanced care plans, documentation and hydration.
Wall also advised the rest home apologise to the woman's family.
In the report, the rest home said it acknowledged that there were missed opportunities and shortcomings in the care provided in the woman's last 24 hours.
They said that it deeply regrets the events that occurred and offered its "sincerest apologies" for the distress caused to the woman and her family.