The Counties Manukau District Health Board has been criticised for failing to give antibiotics to a patient suffering from a serious infection after surgery.
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The man, in his early 60s, died in 2011 after medical staff withheld antibiotics from him, despite knowing he had sepsis.
Health and Disability Commissioner Anthony Hill said the man should have received antibiotics and the decision to withhold them was inappropriate.
Mr Hill said his research showed that the man could have survived the infection if he had better care.