"An orderly brought him into the hospital ED yet no medically trained person took responsibility to assess Neil's health," he said.
Jones was trespassed from the hospital for being a "nuisance to staff and patients" and left at a shelter by police, although the coroner noted no evidence was presented about Jones' interactions with anyone at the time.
When Jones started vomiting blood, he was taken back to the hospital, where he died two days later.
Jones' mother, Joan, told Radio NZ she was disgusted by how her son was treated.
"With dogs and things like that, you'd have put them down or you'd look after them. You wouldn't let them die like that on the street, in the bus shelter all day," she said.
"I was disgusted. I just really couldn't believe it. I still find it very hard to believe to be quite honest."
Canterbury DHB chief executive David Meates says he has personally apologised to Jones' family and that changes have been made at the hospital to prevent similar things happening again.
- NZN