A 69-year-old woman was treated for depression at her rest home, when she actually had a stroke.
Kauri Lodge in Kaeo has been criticised for their care of the woman by the Health and Disability Commission, being told it should have listened to her family more.
In her report, Aged Care Commissioner Carolyn Cooper said the woman - known as Mrs A - had been happy, content and settled at the home.
She used a walking frame to move around the home to see friends, had visits out with family and was and described as an "independent lady" by a staff member.
But over a period of about three months, in 2021, she deteriorated rapidly, and eventually died.
Her family had raised concerns she had a stroke because of a loss of strength she had one side and limited speech.
But staff assured them she had depression and was prescribed anti-depressants.
Staff had noticed Mrs A's loss of strength in her right arm and leg, her trouble speaking, new inability to feed or wash herself, and a very low mood.
But they missed multiple chances to properly escalate her care, the commissioner said.
They knew her well and should have known she was not her usual self.
At one stage she was found on the ground after having a fall, but there was "no record of GP or nurse practitioner involvement", the commissioner said.
Her daughter had been overseas and worried about Mrs A's deterioration after a phone call.
She raised concerns and then again a few days later, when she returned from overseas, found her mother only able to say yes or no.
She and her father told staff they thought Mrs A had a stroke but that's when they were told about the apparent depression, the report said.
About a week after her family raised concerns, Mrs A was seen by a GP who diagnosed a stroke.
He considered calling an ambulance but realised she was outside of the time frame for clot retrieval, after nurses told him Mrs A had right side weakness for about a week.
"For an ambulance to arrive at Kauri Lodge in an urgent call is usually at least 40 minutes, and to travel to [a public hospital] where the decision is made for thrombectomy, a further 2.5 hours and then transport to [a tertiary hospital]. On the day the weather conditions were too poor for helicopter transport from the town with low cloud," he told the commission.
It was at the height of the Covid pandemic and he worried about her catching the virus.
Soon after her consultation, Mrs A was moved to the hospital wing where she died a few weeks later.
Commissioner Cooper said Kauri Lodge failed to provide Mrs A with adequate care after failing to conduct nursing assessments and escalate her care in time.
They should also have paid more heed to the concerns of her family, she said.
She has told the home to train staff on how to better escalate deteriorating residents and improve its record-keeping.
Kauri Lodge told the commission it had already made changes, including regular performance reviews with staff and bi-monthly training.
Cooper also criticised the doctor for not performing more tests when he saw the woman, and for taking inadequate notes, but found he did not breach the Health and Disability Code.
