Wellington, Nov 17 NZPA - A diabetic woman died after health providers missed valuable opportunities to treat her, an investigation has found.

Maureen Pineki, 68, died in Auckland City Hospital's intensive care unit on September 12 from a a critically low level of glucose in her blood -- hypoglycaemia, according to an Auckland District Health Board report obtained by the New Zealand Herald.

`On the information provided there appeared to be a number of missed opportunities for intervention to reduce Mrs (Pineki's) insulin dose," the report said.

Auckland's new medical laboratory provider Labtests is criticised in the report, along with the medical centre which ordered blood tests, and an ambulance crew who treated Mrs Pineki.

The report said Mrs Pineki's call to her GP's clinic was handled by a nurse but her concerns were not passed on to the doctor.

The nurse ordered a home-visit blood test but did not make any special note of Mrs Pineki's reported hypoglycaemia, which resulted in the tests being treated as "routine".

The results were found to be critically abnormal, but a delay in processing meant it was unclear if this was real, or caused by natural breakdown in the blood sample.

Labtests should have urgently contacted the medical centre, the report said. On receiving the Labtests fax, which probably "downplayed" his interpretation of the results, Mrs Pineki's GP tried once to phone her, but got no answer.

That morning, an ambulance crew was called after Mrs Pineki fell. They gave oral glucose, without determining her history of hypoglycaemia, "which would have indicated transport to hospital was required".

Labtests said the report's authors had told the organisation its handling of the tests did not directly lead to Mrs Pineki's death.

However, her family told the paper they were not satisfied with the report and were planning to consult a lawyer about her treatment.

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