A patient at a Wellington resthome with dementia and multiple sclerosis had a fractured shoulder and hip for more than two weeks before he was taken to hospital, where he died before he could undergo surgery.
Coroner Ian Smith has found Robert Wilson Jarvie, 86, died of complications from his injuries after he fell out of his bed at the resthome last April 11.
Mr Jarvie, who could no longer speak and was confined to bed in Cashmere Hospital for the last two years of his life, was attended to by a nurse after he fell out of bed.
The nurse was satisfied he had only minor injuries, including scratches to his skin and bruising, but later faxed Mr Jarvie's doctor at the request of his daughter.
Dr Alistair Young did not see Mr Jarvie until his next scheduled visit, on April 15, as was standard practice for non-urgent callouts.