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.
Investigation findings
The investigation spoke with patients, carers and families – including those whose loved one had died, and NHS staff. We also reviewed serious incident reports.
Examples of harm cited in the report include:
- Insulin infusion being stopped (before surgery) and then not restarted, contributing to a patient’s death.
- 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.
- Insulin at the incorrect dose (too high) being administered, contributing to a patient’s death.
- 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.
- 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 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 us 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 – teams which are often under resourced and unavailable out of hours or seven days a week. In addition, we identified inconsistent reporting and oversight of inpatient diabetes safety across local, system, and national levels. These gaps can create safety ‘blind spots’, making it harder for organisations to recognise patterns, learn from harm and drive coordinated improvement.
Safety recommendations
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 NHS trusts to help them consider how they can take action to mitigate the safety risks identified in this report.
Investigator’s view
Craig Hadley, Senior Safety Investigator at HSSIB, said: “Our 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.”
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