A elderly man died after being left without enough food and water for nearly two weeks in a hospital, an investigation has found.
Health and Disability Commissioner Anthony Hill has released a report into the treatment of the 89-year-old who died following hip surgery at a Waitemata District Health Board hospital which found "critical thinking was lacking" on the part of staff.
The man, who had several medical conditions, frequently refused drink or food during his stay and on occasion pulled his intravenous fluid lines out of his arms, leading to clinical dehydration and delirium.
A dietician was not called in until the 13th day of his admission.
The man, who was moved to four different wards during his stay, died the following day.
"An assessment of the man's nutritional status should have been undertaken much earlier, and the planning and evaluation of the oral care provided to the man by nurses was unsatisfactory," the report said.
"I am concerned that a dietician referral did not occur until day 13, when the physiotherapist made the referral. By this time, [the patient] had been in hospital for 13 days without adequate oral intake."
The report also found the man's pain management was "ad hoc" and not monitored properly.
Mr Hill asked the DHB to apologise and made several recommendations about staff training and monitoring of pain and nutrition levels.