The Health and Disability Commission says a North Canterbury Rest Home patient who died of septicaemia deserved better.
The Commission found staff at Ultimate Care Karadean Court in Oxford failed to respond to the elderly man’s deteriorating condition.
They've been ordered to apologise to his family, undergo an audit and improve training and staff levels.
Deputy Health and Disability Commissioner Rose Wall told Chris Lynch the man had complex health issues - like diabetes, heart disease and dementia.
She says he wasn't well, and he deserved a good standard of care that kept him as comfortable as possible.
"I have referred the case to the director of proceedings - to see if any further action's required."
Wall says Ultimate Care could be taken to the Human Rights Review tribunal - where it might be ordered to pay the patient's family compensation.
Ultimate Care has been approached for comment.