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An elderly man recovering in hospital from a hip operation fell and caused himself further injuries when staff failed to answer his call for help to go to the toilet.
He then waited more than 20 days for repeat hip-replacement surgery in Auckland City Hospital and died after his condition worsened.
The hospital has apologised over the case.
Alfred Hudson was heading to the toilet on his own after he pressed the buzzer and no one came to help, said his daughter Lois.
More than once following the first operation - a partial right hip-replacement in May 2005 - he had buzzed for assistance and been left too long, said Ms Hudson, who is fighting for greater acknowledgment of her father's case.
His care was "inhumane" and she wanted to prevent recurrences.
It follows the death of Mervin McAlpine, 82, after a medication mix-up at Auckland City Hospital in 2004, which was highlighted by Health and Disability Commissioner Ron Paterson on Tuesday.
Aged 89 at the time of his first hip operation, Mr Hudson had been living independently at the Roskill Masonic Village complex. He fell, fracturing the neck of his right femur. It was replaced by an artificial hip ball.
After the second fall, in hospital, he was repeatedly bumped off the surgery list by more-urgent cases, each time having to go without food and drink in preparation for the operation - although the hospital said clinical reasons, such as infection risk, getting his anaesthesia right and pre-surgical investigations, contributed to the deferrals.
Ms Hudson said being starved five times contributed to her father's death in April last year, 11 months after the first accident.
"By the time he did have the much needed surgery after 20 days, he had lost condition and his body's fighting power was greatly diminished. It's inhumane to leave someone in a hospital bed in that condition for 20 days."
After that surgery - a total hip replacement - he suffered a persistent hip infection. It was washed out several times but worsened. The artificial joint was removed in August 2005 in a third operation, leaving Mr Hudson with no right hip.
He was declared cured of his hip infection the following month, but subsequently had bouts of excruciating hip pain.
His death certificate says he died of bronchopneumonia, generalised debility, congestive heart failure and his hip surgery.
ACC initially declined a claim that his hip injury caused his death, but last month reversed that decision after an independent geriatrician concluded the fracture and later complications had contributed.
Ms Hudson also complained to the commissioner's office, which reviewed the case but declined to undertake a formal investigation, saying it "would not elicit any more information".
Acting commissioner Tania Thomas wrote to Ms Hudson that, when delayed for surgery, her father was "essentially on a waiting list".
"While I acknowledge your frustration at these events - many of which are not totally uncommon scenarios in a public system with finite resources - I am satisfied that the district health board's response outlines genuine reasons for the delays in surgery."
The hospital's chief medical officer, Dr David Sage, told the Herald its responses, apologies and explanations regarding the delays in Mr Hudson's surgery had been found to be reasonable. The hospital was "most unhappy" at having to defer operations because of more-acute cases, which was unfair and costly.
"We are currently investing heavily in several surgery projects to address resource and scheduling of acute cases. The aim is to make such delays very uncommon, although realistically they can never be completely eliminated."
