A dying Christchurch man was discharged by the hospital and dumped at a bus station because a doctor thought he was faking.
Neil Jones died in October 2013 after a doctor thought he was "looking for a free ride", the coroner's report, published on Thursday, has found.
The 47-year-old was ditched at a bus station wearing just hospital pyjamas, lying on the footpath for hours as members of the public tried to get help for him.
After being taken back to the emergency department, he was removed by police without assessment or treatment, and trespassed from the hospital.
Taken to the city mission, he began vomiting blood and was taken back to hospital. He died two days later.
Christchurch Public Hospital, the Canterbury District Health Board and police have been criticised in the report.
The 47-year-old was an alcoholic and homeless. Nurses and security staff had protested when he was discharged, but he was left alone at a nearby bus stop.
One security staff member said he didn't want to kick Mr Jones out, but "the doctors are pretty much God and you've got to do what they say".
Dr Richard Geary, who was Mr Jones' physician before he died, told a security staff member he thought Mr Jones was "looking for a free ride".
In 2008, Mr Jones started drinking heavily after his partner committed suicide. He was so dependent on alcohol, he would become ill if he didn't drink.
He'd tried to get help but there were no beds at local rehab clinics. If he had been able to get help, he could still be alive, the coroner said.
In the months before he died, he was drinking three litres of vodka a day.
"[His daughter said] Neil had wanted to stop drinking, that he had reached the point where he hated alcohol and the taste of it, but was unable to stop consuming alcohol on his own," the report said.
When police removed Mr Jones from the hospital to take him to the Mission, then didn't come back to take him to the hospital when it turned out he was seriously sick, "does not in my view represent initiative and good policing", the coroner said.
CDHB chief executive David Meates says the system failed Mr Jones and he's apologised his family.
"When significant failures in care occur, as they have in this case, we can look back and identify many things we would do differently," he said.
He says changes have since been made which mean there won't be "a repeat of the unfortunate chain of events which prevented Mr Jones from receiving further medical treatment sooner, and didn't allow him to die with dignity".
One of the changes, CDHB told the coroner, would allow and encourage staff to raise any concerns they have and "empower them to take those concerns further if they need to".
Mr Jones died of alcoholic liver disease, the coroner found. He was 47.