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

We have launched an investigation that 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.

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.

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.

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 an investigation will consider:

• 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?

We will begin this work by focusing on people with mental health diagnoses at risk of suicide. We expect to publish this first report in January 2026, with two further reports covering older people with memory difficulties and people with a learning disability being published in May 2026 and July 2026.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience. If you would like to speak to us about these investigations before we publish the reports, please email enquiries@hssib.org.uk.