Health New Zealand | Te Whatu Ora Capital, Coast and Hutt Valley breached the Code of Rights by failing to ensure coordinated care for a 75-year-old woman with diabetes who suffered a severe hypoglycaemic episode, the Health and Disability Commissioner has found.

The woman, identified as Mrs B, lived alone and had multiple health conditions, including type 2 diabetes. She had been admitted to hospital four times in the previous eight months with hypoglycaemia. District nurses and healthcare assistants (HCAs) supported her diabetes management in the community, with HCAs prompting blood-sugar monitoring and self-administration of insulin under nurse delegation.

On 16 May 2021, an HCA recorded Mrs B’s blood sugar at 3.6 mmol/L and phoned a district nurse. The nurse, who did not know the patient, was driving and could not access clinical records due to a system outage. She was therefore unaware the woman’s GP had set a higher target range of 10–15 mmol/L two weeks earlier. Relying on the HCA’s description that the woman was alert and oriented, the nurse advised prompting insulin and ensuring Mrs B ate sugar and carbohydrates. A scheduled home support visit later that day did not occur due to rostering issues. Around 5.30pm, Mrs B was found unresponsive. Her blood sugar was 3 mmol/L; she went into cardiac arrest during ambulance transfer, suffered significant brain injury from lack of oxygen, and died in aged residential care in late October 2021.

Deputy Commissioner Rose Wall found Health NZ breached Right 4(5) of the Code, which guarantees cooperation among providers to ensure quality and continuity of services. She said the district nurse had insufficient information at the time of the call to assess the need for a visit, and critical details that should have been available in the clinical record—such as the GP’s target range and recent dose increase—were not accessible due to systems and documentation gaps.

The decision notes communication during the call also broke down, with important context about the woman’s history and target range not relayed. Wall said it was not reasonable to expect an HCA to convey that level of clinical information; it should have been obtained from the patient’s notes.

The case unfolded against a backdrop of inconsistent documentation. In the days prior, most recorded blood-sugar readings sat outside the GP’s target range. The woman’s readings included a morning low of 5.9 mmol/L on 13 May, when a district nurse advised withholding insulin, and evidence later supplied by the family of a 3.3 mmol/L reading on 14 May.

A Serious Event Review by Health NZ found:

• The long-standing practice to review a patient face to face after a hypoglycaemic event was not formalised or documented.
• There was no standard care plan template for diabetes.
• Blood-sugar readings were not recorded in a consistent location, hampering clinical oversight.

Health NZ accepted the findings and apologised to the family for “the breakdown in communication that occurred, which impaired the delivery of critical information necessary for Mrs B’s care.”

Mr A, the woman’s son, told the HDC his complaint centred on a nurse overdosing insulin. The Deputy Commissioner did not make a finding on that point, concluding the inadequate care resulted from system failures rather than an individual error.

Since the incident, Health NZ said it has:

• Stopped delegating prompting of blood-sugar monitoring or insulin administration to HCAs.
• Introduced a standard diabetic care plan template accessible to staff.
• Created a blood-sugar chart, with completed charts sent monthly to the patient’s GP.
• Implemented clinical nurse specialist oversight for community patients requiring insulin.
• Delivered staff training on the new plans and charts, including at orientation.

The Deputy Commissioner recommended Health NZ provide a written apology to the family. No further recommendations were made, with the Commissioner satisfied the review identified and addressed the main issues.

An anonymised version of the report, naming Health NZ Capital, Coast and Hutt Valley, will be published on the HDC website for educational purposes.