Change urged after death of diabetic

An investigation has found that health providers, including Labtests, "missed opportunities for intervention" in the days before the death of a 68-year-old diabetic.

Maureen Pineki died in Auckland City Hospital's intensive-care unit on September 12.

The main cause was a critically low level of glucose in her blood - hypoglycaemia - caused by her using too much insulin.

Following a request under the Official Death brings call for change to the Information Act, the Herald has obtained a copy of the Auckland District Health Board's report.

It says: "On the information provided there appeared to be a number of missed opportunities for intervention to reduce Mrs [Pineki's] insulin dose."

Labtests said yesterday the report's authors had advised it that the laboratory matters in the report did not directly lead to Mrs Pineki's death..

Mrs Pineki's family are not satisfied with the report.

"I'm going ahead to consult a lawyer," said her daughter, Marie Hanson-Alp. "It's not about suing anybody; it's about them standing up and having accountability for what happened to my mother."

The report says Mrs Pineki had limited understanding of her diabetes and had repeatedly cancelled Diabetes Centre appointments because of pain and mobility difficulties.

She told her GP clinic's nurse by phone on September 7 she was suffering hypoglycaemic episodes. This was not reported to her GP. The nurse ordered a home-visit blood test.

A Labtests employee took the samples on September 8.

The medical clinic had not reported hypoglycaemia or any medical details on the order form, so the tests were processed as "routine".

The lab report was faxed to the clinic the next morning.

The results were critically abnormal, but a delay in processing meant it was unclear if this was real, or caused by natural breakdown in the blood sample. Another tube of blood containing an added chemical to restrict the breakdown of glucose in blood was not tested.

The report says Labtests should have urgently made direct contact with the test requester.

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, but did not elicit the history of hypoglycaemia, "which would have indicated transport to hospital was required".

On September 10 she was taken to hospital suffering a severe hypoglycaemic coma. She died two days later.

St John said its staff followed correct procedures. The ambulance service agreed with the report's recommendations.

The managing partner of the GP clinic, Stoddard Road Medical Centre, declined to comment because he had not seen the report.


RECOMMENDATIONS

LABTESTS:

Review systems to ensure timely testing, especially of samples prone to rapid chemical breakdown.

Give more explicit guidance on response to critically abnormal results.

THE MEDICAL CENTRE:

Review systems for contacting patients with critically abnormal results.

Talk to District Nursing Service and Diabetes Centre to improve co-ordination of patients who repeatedly miss appointments.

ST JOHN AMBULANCE SERVICE:

Write guidelines on communicating with GPs when patients seen but not taken to hospital.