A dementia patient died in a hospital stairwell due to low blood sugar after being inadequately monitored and delayed care.

A 79-year-old man with dementia, diabetes, and heart disease died in a Waikato Hospital stairwell in December 2019 after wandering from a coronary care unit. He was found unconscious with a blood glucose level of 1.8 mmol/L after being missing for 76 minutes. The Health and Disability Commissioner found the hospital breached patient rights due to inadequate monitoring, delayed response, poor diabetes care, and lack of alert systems. Staff failed to act despite CCTV showing him passing multiple personnel and a fridge lacking diabetic snacks. The hospital has since implemented changes including stocked fridges, staff training, door alarms, and a patient-tracking system.