A man who died of a heart problem less than a day after being discharged from an intensive care unit was let down by the the Nelson Marlborough District Health Board, the health watchdog says.
Health and Disability Commissioner Anthony Hill on Monday released a report criticising a decision by staff to release the man - who had complicated physical and mental health problems - from their care.
The man ended up in an intensive care unit after having a heart attack while visiting a public hospital's emergency department twice in two days for unrelated issues.
Despite a blood test revealing there was some abnormality with the man's heart, a cardiologist - unaware the test had been run - declared him fit and discharged him to a mental health facility after a day.
Although staff at the facility checked on him every 10 minutes, he was found dead in his room from a heart condition in the morning.
Mr Hill said the discharge was inappropriate, staff hadn't recognised the level of damage that had been done to his heart and failed to use his blood test as a guide for further care.
The DHB's processes meant different providers didn't co-operate properly and documentation was "suboptimal", he said.
The commissioner recommended a series of changes at the DHB, including introducing an alert system about certain blood tests, changes to audit and risk-management policies and more training for staff.
It also asked the DHB to apologise to the man's family.