The Waitemata District Health Board has been faulted over its care of an 89-year-old man who was taken to hospital by ambulance following a fall while out walking.
Health and Disability Commissioner Anthony Hill, in a decision made public today, said the DHB had breached the code of patients' rights in its care of the man.
The man, who is not identified in the report, died on his 15th day in hospital, which was in 2012.
Following the fall, the man, who had several chronic illnesses, was found to have a hip fracture and on his ninth day in hospital he had surgery.
"A range of oral and intravenous medications was given to alleviate his pain, minimise his confusion and reduce his vomiting. However, often he refused oral medications, and sometimes the intravenous line did not work properly," Mr Hill said.
"[He] also frequently refused food and drink. He was given fluids intravenously and subcutaneously."
"[He] had become confused since his fall, and was very restless during his time at the public hospital."
Mr Hill said he was concerned that within the man's clinical notes "there are blank assessments, and inadequate or blank care plans, and clinical requests have been made but not actioned".
His nursing adviser told him that the four wards in which the patient was cared for had operated as "information silos".
"I accept that since these events Waitemata DHB has put in place a number of new initiatives, which may minimise the risk of the shortcomings identified in this case being repeated."
However, Mr Hill said, the assessment and management of the man were "sub-optimal with regard to his pain, oral care, nutrition and fluids".
He made recommendations to the DHB on how to lift its standards, including training its staff on the importance of monitoring of pain, oral care, nutrition and hydration.
The DHB's chief medical officer, Dr Andrew Brant, said it fully accepted the commissioner's findings.
"I have apologised to the patient's family for not delivering care to the standard we would expect to provide for our patients. The DHB acknowledges the concerns the patient's family has raised and we are sorry for the distress this has caused.
"Over the last three years, we have instituted a number of initiatives to ensure we deliver consistent high-quality care to patients within our hospitals. These include specific programmes around the management of pain, nutrition, fluids and oral care. We regularly audit our wards to ensure that our expected standards of care are met.
"Waitemata DHB has a major focus on patient and family experience, which results in a stronger voice for our community in shaping our services. While the challenge of improving patient care is ongoing, this patient's story is a reminder to us about the importance of 'getting it right' for each and every patient and their family."