Failings in the care of a woman with Type 2 diabetes - who died from a bacterial groin infection

The Deputy Health and Disability Commissioner has found her right to an appropriate standard of care was breached, over two-months.

The woman turned up to Kaitaia Hospital several times - and was also admitted.

She eventually had amputations of a toe and below the knee - and further surgery.

Rose Wall says clinicians failed to assess or adequately consider the cause of her ulcers - and didn't refer her to the vascular service or diabetes clinic.

Health New Zealand has made a number of changes since - while Wall has made further recommendations.