An Auckland woman's death in hospital from an overdose of insulin was not accidental, a coroner has found.
Heather Bills died at Middlemore Hospital in 2013, six weeks after after being admitted with severe burns from a deliberately-lit house fire at her Orakei home.
The 64-year-old suffered an irreversible brain injury after being given a large dose of insulin.
The chief coroner, Judge Deborah Marshall, said Ms Bills could not get out of bed to source the insulin herself.
She said it was either administered to Ms Bills by someone else or handed to her for her to take.
The nurse in charge told the coroner that opened bottles of insulin were kept in a drawer and were not accounted for.
Judge Marshall said she was "unable and unwilling to attribute blame to any individual involved in the care of Mrs Bills for the failure to initially note the very low blood glucose levels" that were recorded in the early hours of the morning.
She found that the cause of the death was a "non-accidental overdose of insulin".
In a statement, police said they would review the findings and their own investigation into the case.