The Lakes District Health Board has been criticised for failures to care for a man who went to the hospital's emergency department with sepsis.
The man in his 20s has a history of Crohn's disease, and arrived by ambulance in 2018.
Deputy health and disability commissioner Rose Wall said the man was in the emergency department for about six hours and there were differing opinions about where he should be taken and cared for.
He was moved to a unit where his condition deteriorated and his family pushed for a consultant to do a review.
The sepsis was picked up and he was given IV fluids and antibiotics.
"Sepsis is a potentially life-threatening condition that necessitates prompt and at times aggressive treatment," Wall said.
There were multiple failures by the DHB, including a delay in the man getting appropriate care, she said.
"[The man] was left in pain, with no specified person taking responsibility for his treatment, for a protracted period of time, and there was a significant delay in arranging medical review and appropriate treatment," she said.
Wall has made a number of recommendations and the DHB must apologise.