The findings of Coroner David Crerar, released this week, found the woman, whose identity has been suppressed, died in Dunedin Hospital after she administered herself 10 times the amount of insulin she was supposed to take.
Contacted about the case yesterday, Dunedin-based specialist endocrinologist Associate Prof Patrick Manning said most diabetics these days used special pens, but if they needed to use a syringe for any reason, it should be a specific insulin syringe on which the measurements for insulin were clearly marked.
The measurements on other syringes were not easy to use to measure insulin correctly and should be avoided.
Police requested Prof Manning' s professional opinion on the death of the woman in October 2008.
The coroner's report noted Prof Manning's opinion was that there was "no doubt" the woman had accidentally received the excessive doses of insulin and that doses that large would result in significant and prolonged hypoglycemia in someone with type 1 diabetes, as the woman had.
Pens contain a 3ml cartridge of insulin equating to 300 units.
A common dose of insulin is 15-20 units.
The woman had misplaced her insulin pen and while waiting for a replacement was using a tuberculin syringe, which is not marked clearly for measuring amounts of insulin and requires the user to calculate how much to draw into the syringe, the report said.
On one night the woman drew off and injected 1ml (100 units) of insulin from a 3ml vial and then drew off and injected another 1ml, equating to 200 units or 10 times her usual dose.
The next night she administered another 1ml of insulin (five times the required dose).
She could not be woken the next morning and was taken to Dunedin Hospital, where she later died.
Police were satisfied the death was accidental.
"Prof Manning suggests that only insulin syringes should be used for the administration of insulin and the use of the tuberculin syringe should be discouraged," the coroner's report said.
The nurse who supplied the woman with the syringes told police in a statement she had asked the woman if she had used the particular syringes before, and the woman said she had.
Prof Barry Taylor, the co-chairman of the Otago Local Diabetes Team, said it was fairly common knowledge that tuberculin syringes should not be used to administer insulin, as it was easy to make a dosing mistake.
He understood the common practice at Dunedin Hospital and with most GPs was not to use such a syringe to administer the drug.
Mr Crerar said he could not attribute any blame or responsibility to any person for the "tragic events" that resulted in the woman's death.
Errors, which had been acknowledged, had been made and a series of small contributors had resulted in the death.
He hoped his report would draw attention to the potential problems of administering insulin in inappropriate doses or by inappropriate means.
