Legal action and fundamental reform of the aged care sector is being urged after a report into the death of a woman at a Timaru rest home.
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The woman, who was in her 70s, was not able to get in or out of bed on her own.
Deputy Health and Disability Commissioner Rose Wall found the Radius Elloughton Gardens rest home in Timaru breached the Code, after the woman suffered serious injuries in their care in 2018.
The woman fell out of bed in 2018 and died days later.
Staff at the Timaru rest home claimed to have been unaware of how the woman suffered multiple fractures, despite an investigation saying it's most likely someone was with her at the time.
The rest home said it had apologised to the family for what happened in 2018.
President of the local Grey Power chapter Jock Anderson said an apology was not enough.
Anderson told Morning Report he wanted to see legal action and voiced scepticism that the government's announcement last week of a new Aged Care Commissioner would help bring about changes needed to the profit-based model of care operating in New Zealand.
"Clearly in this particular case at Elloughton Gardens the staff and their care system failed and tragically in the case of this lady, who it was obvious needed particular care. She had a long history of ill health," he said.
"I think Radius, who own this care retirement village, I think they should be prosecuted to the full extent of the law. I think that the staff and management who were on duty and who were responsible for the care of this lady, should also be prosecuted. Some might say that this is a case where Radius itself should not be allowed to run such facilities.
"If they cannot provide what I would have thought was basic professional well-trained care for a lady who clearly needed it, then they shouldn't be in the business."
Since the incident, the rest home has been working with the South Canterbury District Health Board to improve training for nurses and provide better care.
Deputy Commissioner Wall said the care facility had breached its code of care. An ambulance was called five hours after she was discovered to have multiple fractures to her shoulder and legs.
"Significant systems issues were present at the rest home which in my opinion compromised the quality of the care provided to her," Wall found.
Anderson said the case wasn't unique and reflected wider, systemic problems within the sector that needed addressed.
"We are seeing numerous cases over recent years as more people prepare to speak out. There have been numerous cases where elderly folk are either being abused or neglected in the elder care sector and when you consider the retirement home industry is a business, its primary function is to make money for its owners and shareholders. If by going along that path they can provide some care to older folk that's how they make their money."
He remained sceptical that the new position of Aged Care Commissioner announced in the Budget by the government last week would be sufficient to bring about fundamental reforms needed to transform the model from profit-orientated to care-orientated.
"I think they should be prosecuted to the full extent of the law" - President of Grey Power Timaru, Jock Anderson
"It's taken three years to get a report from the Deputy Health and Disability Commissioner on this particular case.
"No amount of commissioners and beefing up the bureaucratic forces is going to change anything unless change happens right at the heart of it and that is right at the heart of the aged care industry at the retirement homes," Anderson said.
Clarification: An earlier version of this story stated staff at the rest home failed to identify and respond to signs of dehydration and deterioration. This was incorrect, and referred to a separate, previous case at the same location.