The Canterbury District Health Board failed to support a man with alcoholic hepatitis and inappropriately discharged him two days before he died, according to the Health and Disability Commissioner.
In a new report released on Monday, Commissioner Anthony Hill found the man was escorted from the hospital by security staff and taken to a nearby bus stop while wearing hospital pyjamas despite sill being unwell.
The man is not named by the commissioner but was identified by the coroner in 2017 as Neil Jones, who died in October 2013.
In the latest report, Hill says about three weeks after being admitted to Canterbury's Gastroenterology Department, Jones was discharged despite still being sick and requiring ongoing medication, as well as having no suitable accommodation arrangements in place.
Jones was then left at a bus stop wearing just hospital pyjamas.
"He remained at the bus stop for many hours. During that time, members of the public and security staff raised concerns about his condition, but he was not assessed by hospital staff.
"Later in the day, the police were called to remove the man.
"He was issued a trespass notice and taken to a social service agency. While there his condition deteriorated further and he was returned to hospital, where he sadly died two days later."
Hill criticised the health board for a "lack of effective response to the man's need for help" and recommended an apology to Jones' family.
Other recommendations included auditing "the operation of its new trespass policy, reviewing the Gastroenterology Department staff's ability to access test results, and developing the protocol for the readmission of patients".