A rest home failed a man suffering from prostate cancer during his week-long stay for respite care in 2014, the Health and Disability Commissioner has found.
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An investigation by the commissioner found the 77-year-old man's catheter was removed without medical advice, he was not monitored regularly and there was no management plan for his care.
He died in hospital a few days later.
The company, Bupa Care Services, must apologise to the man's family and has been told to better train its staff.
The rest home has not been named in the public report.