In the report the man has not been named but previous stories written by the NZ Herald identify him as Neil David Jones, who died in October 2013 at the age of 47.
Health and Disability Commissioner Anthony Hill released the report on Monday, which found the CDHB breached the Code of Health and Disability Services Consumers’ Rights for "failures in the care provided" to Jones.
“The man was considered to be deliberately engaging in behaviour intended to prevent his discharge,” a Health and Disability Commissioner spokeswoman said.
“The man was escorted from the hospital by security staff and taken to a nearby bus stop while wearing hospital pyjamas.
“He remained at the bus stop for many hours. During that time, members of the public and security staff raised concerns about his condition, but he was not assessed by hospital staff.
“Later in the day, the police were called to remove the man. He was issued a trespass notice and taken to a social service agency. While there his condition deteriorated further and he was returned to the hospital, where sadly he died two days later."
Coroner Michael Robb noted in his report into the death that nurses and security guards questioned the decision, saying Jones was too ill and had nowhere to go.
After lying in the bus stop for several hours, Jones was brought into the emergency department, but not assessed.
Police took him to the Christchurch City Mission, where he began vomiting blood.
He was then readmitted to hospital, where he died.
Jones' mother, Joan, said she was disgusted at the hospital's actions. Even though he was an alcoholic, he was dying and should never have been kicked out onto the street, she said.
"With dogs and things like that, you'd have put them down or you'd look after them. You wouldn't let them die like that on the street, in the bus shelter all day," she told RNZ.
Jones spent most of the day lying in the bus stop where passers-by tried to get doctors to help him.
"The hospital kept saying 'no, it's fine, he's only putting it on, leave him alone'... they didn't want to know," Mrs Jones said.
"They were saying that he was only looking for attention, that he was faking it.
"I was disgusted, I just really couldn't believe it. I still find it very hard to believe to be quite honest."
He found the CDHB was in breach of Right 4(1) of the Code for discharging Jones while he had unresolved medical and accommodation issues, and for failing to reassess him, issuing him with a trespass notice, and requesting the police remove him from the hospital.
He also found the CDHB breached Right 3 of the Code for failing to respect Jones' dignity, saying "there was a striking lack of compassion" in failing to take seriously the concerns raised by security staff and members of the public.
Mr Hill recommended the CDHB apologise to Jones' family, audit the operation of its new trespass policy, ascertain whether staff in the Gastroenterology Department feel free to raise concerns and escalate these if necessary, review the department staff’s ability to access test results and develop a protocol for the re-admission of patients who re-present following discharge.
