A caregiver and his employer have been slated after a young disabled man died while in their care in late 2013.
The unnamed caregiver failed to follow instructions in his care of the 20-year-old which led to his death after he stopped breathing in his bed at the residential facility run by Auckland-based Creative Abilities and Associates Limited.
Deputy Health and Disability Commissioner Rose Wall says the caregiver did not use a shoulder harness after moving him into his wheelchair, or place a pillow under the man's head and shoulders after putting him back in bed.
"In my opinion it is unacceptable practice for any care giver to ignore the instructions in a care plan which has been developed," she said.
His employers were also slammed for allowing the caregiver to work unsupervised in a sole charge role after earlier being found asleep on the job.
"The the hours Mr C was allowed to work following a disciplinary process put at risk the clients he cared for, including Mr A."
She said there was no record of performance appraisals and Creative Abilities did not monitor the caregiver's performance issues adequately.
The company also did not have systems in place to ensure the caregiver had accessed or received information and it had failed to minimise the potential harm to the client.
Ms Wall recommended both the caregiver and employer write apologies to the dead man's family and the company review and update its procedures.