Two nurses failed to provide appropriate care to an elderly man who died after a fall in a residential home, a report has found.
The man, who had an intellectual disability and diabetes, required help with mobility, deputy health and disability commissioner Rose Wall said in her report on the case.
Several days after the unwitnessed fall, an enrolled nurse noticed the man was in discomfort.
She told the registered nurse on duty that his breathing was laboured, his skin was clammy and he wasn't responding to commands.
The man was given paracetamol elixir in accordance with his prescription, but 20 minutes later stopped breathing.
The enrolled nurse, who was sitting with him, didn't commence CPR, but contacted the registered nurse, who arrived at the home shortly after and called police.
Ms Wall said the registered nurse should have contacted emergency services or the on-call doctor when told of the man's laboured breathing and clammy skin.
She was critical of the enrolled nurse's failure to start active CPR and to ring emergency services when the man's breathing stopped.
Ms Wall recommended that the residential home review its plans for the care of all residents with a high risk of falls and provide training on its resuscitation policy.
She also recommended that the two nurses apologise to the man's family and that the Nursing Council should consider whether to review the enrolled nurse's competence.