Health authorities in Canterbury have been told to apologise to the family of a 21-year-old man who died following brain surgery.
The man had surgery to relieve headache-causing pressure on his brain in 2008.
The Health and Disability Commissioner's findings, released on Monday, found a number of problems with his post-operative care.
His breathing rate - which was initially checked every hour - was not recorded overnight following surgery and he was found dead in his hospital bed in the special care unit the day after his operation.
The post-mortem found he possibly died because of a "functional loss of breathing control while asleep".
Commissioner Anthony Hill said the Canterbury District Health Board had not provided the man with an appropriate standard of care, and recommended it apologise to his family and take steps to ensure such failures were not repeated.
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