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Persistent risks to safe insulin care in hospitals highlighted in new report


Patients with diabetes who rely on insulin are facing persistent and serious safety risks when admitted to hospital, according to the latest investigation report from the Health Services Safety Investigations Body (HSSIB). The report highlights inpatients have come


to harm or died in hospital because their insulin dependent diabetes has not been appropriately managed. Insulin is a high-risk medication and remains one of the most common causes of harm from medication errors in the NHS. As prevalence of diabetes continues to rise across England, the risks associated with insulin administration for inpatients could become more significant. The investigation spoke with patients, carers and families, including those whose loved one had died and NHS staff. HSSIB also reviewed serious incident reports. Examples of harm cited in the report include: l Insulin infusion being stopped (before surgery) and then not restarted, contributing to a patient’s death.


l Insulin consistently being administered after meals rather than before, contributing to a patient’s death – there were reports that administration after meals then happened ‘occasionally’ in later incidents with other patients.


l Insulin at the incorrect dose (too high) being administered, contributing to a patient’s death.


l Harm caused by patients not being allowed to self-manage their diabetes (and self-administer insulin), and where clinicians did not effectively manage their condition.


l Harm caused by patients having their wearable diabetes technology removed during their hospital stay, and where clinicians did not effectively manage their condition.


Hearing and reviewing the experiences of those affected led the investigation to examine how staff are supported to monitor and care for people with diabetes on wards, how patients are enabled to


making it harder for organisations to recognise patterns, learn from harm and drive coordinated improvement. The report makes several recommendations and observations to support inpatient diabetes care, focused on strengthening regulatory activity, improving the national oversight and assurance, and examining how issues with blood glucose levels may be recognised earlier. The report also contains important safety learning for Integrated Care Boards and local learning prompts for Trusts to help them consider how they can take action to mitigate the safety risks identified in this report. Craig Hadley, Senior Safety Investigator said: “Our


self-manage their insulin safely when appropriate, and the progress made against previous national recommendations. The report found that many patients with diabetes


are not consistently supported to self-administer insulin during hospital stays, despite safely doing so at home. This can lead to disruption in established self-management routines and increase the likelihood of insulin being omitted, delayed, or administered incorrectly. For type 1 diabetes, the investigation heard that approximately 1 in 25 patients in hospital go into diabetic ketoacidosis because their insulin is omitted or they are not given enough insulin to deal with their clinical condition at the time. Staff and stakeholders also told HSSIB that there are national systems to help recognise severely unwell and deteriorating patients (NEWS2 scoring) but that they do not currently account for blood glucose readings. The investigation also found variation in the confidence and training of non-specialist staff to manage diabetes care and highlighted the essential role of inpatient diabetes teams - which are often under resourced and unavailable out of hours or seven days a week. In addition, HSSIB identified inconsistent reporting and oversight of inpatient diabetes safety across local, system, and national levels. These gaps can create safety ‘blind spots’,


investigation shows that, despite the dedication of hospital teams, patients with diabetes who rely on insulin still face persistent and avoidable risks when they come into hospital. When insulin management is disrupted - even briefly - the consequences can be serious as we heard from patients and families who shared their distressing experiences of harm, to themselves or their loved ones. “The investigation reveals a system under strain,


creating difficult conditions that can hinder the safe administration of insulin for inpatients. People with diabetes are typically able to manage their insulin independently, yet this is often reduced or removed in hospital settings. Responsibility then shifts to staff who may lack specialist expertise, but they do not always have reliable access to specialist inpatient teams, which are stretched and not consistently available. “As the prevalence of diabetes continues to rise, the wider health and care system must acknowledge the rising risks and their impact on people receiving hospital care. Our findings and recommendations set out clear actions to reduce these risks and strengthen consistency, accountability, and oversight. Patients should be able to trust that when they come into hospital, the management of their insulin will remain safe, reliable and responsive to their needs.” Visit: https://tinyurl.com/mwbcpywd


Men to get better health support through innovative partnership


Men will be given greater support to live longer, healthier lives through a new multi-million-pound partnership with Movember and People’s Health Trust. The Department of Health and Social Care


(DHSC) will join forces with the charities to support community-led men’s health projects and tackle health inequalities. The Men’s Health Community Fund is backed by £3 million from DHSC with


Movember and People’s Health Trust more than doubling the government’s initial funding to give an overall investment of £6.3 million. It will pioneer an innovative approach - bringing voluntary, community and social enterprise together to play a central role in delivering services and testing new ways to support communities; learn what genuinely works for men; and build better ways of reaching those who are least likely


to engage with traditional services. Grants will back community projects that reach underserved men and boys aged 16 and over, particularly in areas experiencing the greatest disadvantage and at key moments in their lives. This could include: community projects for new fathers; activities supporting men experiencing social isolation; and young men’s social connections and engagement with the health system.


May 2026 I www.clinicalservicesjournal.com 9


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Sherry Young - stock.adobe.com


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