A nurse's competence is being questioned after she failed to properly assess an elderly man who she found shivering outside a nursing home, and later died as a result of the inaction.
The 82-year-old man was found laying on the grass outside a nursing home, cold to touch, barefoot and shivering by the registered nurse as she began her morning shift in early 2013.
He had been there for around half an hour.
Other staff came to help and returned the man to his room and also provided warmer bedding but the registered nurse neglected to do a check-up on him immediately and instead went to a staff handover.
Half an hour later, another nurse checked his vital signs for the first time which indicated he had a very low temperature and the onset of hypothermia.
He died soon after as the hypothermia exacerbated a pre-existing heart condition and chronic obstructive respiratory disease.
Deputy Health and Disability Commissioner Rose Wall found the nurse had made a number of sub-optimal decisions in treating the elderly man.
The first was not assessing the man straight after he was returned to his room, instead leaving two caregivers in charge of his care and deciding that her attendance at handover was more important.
In addition, Ms Wall criticised her decision to delegate his treatment to another nurse, and not checking in on him herself when told about his vital signs.
The Nursing Council of New Zealand has been asked to consider whether to review the nurse's competence and also that she undertake further training in recognising the signs of hypothermia.