A number of shortcomings in Te Whatu Ora Tairawhiti's care of a man in 2019

The man, in his 80s, was at Gisborne Hospital with sepsis and chronic wounds in his big toe -- which led to a leg amputation before he died.

A report's highlighted concerns concerns about ward hygiene, inadequate nursing and little communication.

Aged Care Commissioner Carolyn Cooper says the number and scope of the failures points to serious systemic issues.

The hospital's since worked on improving nursing and forming a consumer feedback council for patients and whanau.