A caregiver who kicked, swore at and maltreated a teenager with autism and Down Syndrome has been referred for possible legal action.
The Health and Disability Commissioner is also criticising the Nelson Marlborough District Health Board and the Ministry of Health over the case.
Anthony Hill says the 15-year-old had high needs and was being looked after at a community home.
Staff soon reported that an unnamed team leader had kicked him, pulled his hair, called him an animal and inhuman, and given him medicines to subdue him.
Mr Hill says it showed a flagrant disregard for his rights, and the actions were a far cry from the care expected of a vulnerable, disabled person.
The family's efforts to find out what was happening were unsuccessful.
Mr Hill criticised the ministry for accepting a DHB assurance too easily, and says the DHB may also face legal action over its failure to resolve the matter quickly.