Insulin: supporting safe self-administration in vulnerable patient groups in the community

Background

Diabetes is one of the most common chronic diseases in England and the number of people with the condition is on the increase. It is a condition where blood glucose levels are too high due to various factors, including problems with the pancreas (which produces insulin). People with diabetes require their blood glucose levels to be monitored and to be maintained within a specified range. Where blood glucose levels are not maintained adequately, short-term and long-term problems can arise for the person which can be life-threatening.

In many people, management of diabetes involves the administration of insulin. Insulin can be administered in various ways including via a needle and syringe, pen device or pump.

This investigation explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of harm because of their circumstances.

We have also launched an investigation to examine risks to patient safety when patients who take insulin are admitted to acute hospitals.

Intelligence review

Issues associated with medications that patients take long-term are a recognised risk to patient safety. We identified the focus for these investigations after reviewing the following evidence sources:

previous HSSIB investigations and insights received
national serious incident reporting system
reports to prevent future deaths issued by HM Coroners
academic and policy literature.

We also engaged with various stakeholders to seek their insights in relation to the risks to patient safety associated with long-term administration of insulin. These stakeholders include representatives from national bodies involved in medication and patient safety across primary, community and secondary care.

Summary of investigation

Evidence suggests that several different patient groups are at risk of insulin-related harm. Some of these groups are particularly vulnerable, with multiple interacting factors that influence their care. We identified that an investigation may offer most learning by focusing on insulin-related harm to:

people with mental health diagnoses at risk of suicide
older people with memory difficulties
people with a learning disability.

For each of these groups the investigation considers:

What are the processes involved in the care of people who self-administer insulin in community settings?
How do people access support for their insulin at the point of dispensing and administration?
How do people access support in the monitoring of their condition and insulin use over time?

Our first report focuses on people with mental health diagnoses at risk of suicide. Two further reports covering older people with memory difficulties and people with a learning disability will be published in summer 2026.

Safety recommendations

NHS England |

Department of Health and Social Care

HSSIB recommends that NHS England/Department of Health and Social Care develops a strategy for improving collaboration between mental health teams and specialist diabetes services, that includes consideration of responsibilities for integrated working at national, regional and local levels. This is to support future integration of services that will benefit all patients with mental health and diabetes care needs, including patients who are required to self-administer insulin and patients with type 1 diabetes and disordered eating.

National Institute for Health and Care Research

HSSIB recommends that the National Institute for Health and Care Research, in collaboration with relevant research and policy stakeholders:

maps the knowledge gaps surrounding type 1 diabetes and disordered eating (including those identified in this investigation); and
assesses the priority and feasibility of commissioning research to help address those gaps.

This is to help develop new knowledge to inform future decisions for the delivery of safe and effective care for this group of patients.

Royal College of Psychiatrists

HSSIB recommends that Royal College of Psychiatrists, through collaboration with relevant stakeholders, develops a strategy that:

supports consistent recognition of patients with type 1 diabetes and evidence of disordered eating; and
identifies associated care responsibilities for providers of mental and physical health services.

This is to help improve the NHS’s recognition of patients who are affected and to support decisions around the commissioning of services.

Safety observations

HSSIB makes the following safety observations:

Organisations involved in the provision of undergraduate and pre-registration education and preceptorship/induction programmes can improve patient safety by ensuring that staff have knowledge of diabetes, an understanding of how and why insulin is a vital treatment for many people with diabetes, and the risks that the use and misuse of insulin can present for patients with a mental health problem.

Organisations involved in the manufacture of insulin pen devices used by the NHS can improve patient safety by:

understanding where devices are being used outside of their intended purpose; and
exploring the potential to design devices that would reduce the risk of intentional overdose of insulin for self-harm.