Substandard care for a 71-year-old man admitted to Gisborne Hospital after a heart attack contributed to his death three years ago, health and disability commissioner Anthony Hill has found.
Tairawhiti District Health (TDH) chief executive Jim Green said the death of the 71-year-old patient in 2009 was tragic and the board apologised unreservedly to his family.
In 2009, the man was treated with drugs to break up blood clots, but basic tasks expected of nurses were not reliably completed, the commissioner's report said.
After two days in the coronary care unit, the man was transferred to a general medical ward for acute patients. The next day his family became concerned about his condition and thought he might be bleeding in his brain.
The man's daughter communicated her concerns to the registered nurse on duty that morning and to the nurses on duty that evening. After taking the man's observations and speaking to him, none of the nurses had any concerns.