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 completed an investigation to examine risks to patient safety when patients who take insulin are admitted to acute hospitals.

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, people with a disability and 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?

Investigation reports

To date we have published three reports:

One final report, due for publication later in 2026, will summarise the investigation series.

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.

NHS England welcomes this report and the series of which it is a part and is developing a detailed response in line with the recommendations, in discussion with other healthcare partners. NHSE will align this with its outputs from the related, forthcoming reports around the administration of insulin, and will update HSSIB with further information on their plans as they develop, setting out its full, formal response once all reports in the series have been released.

Response received on 13 July 2026.

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.

The Royal College of Psychiatrists support this recommendation in principle. Currently the College does not have the capacity to undertake the work involved. This will be kept under review and will be considered further should an opportunity become available.

Response received on 27 April 2026.

NHS England |

Department of Health and Social Care

HSSIB recommends that NHS England/Department of Health and Social Care provides guidance to integrated care boards and community providers setting out expectations for service models that empower and support people to manage and administer insulin in community settings. This is to support recognition of models that have safely, effectively and equitably engaged patients, their families and carers, including through the use of modern diabetes technology for self-management.

The Community Nursing team within the national nursing directorate, will lead on and establish a short life task and finish group, to oversee delivery of both recommendations.

Membership will be drawn from existing networks drawing on relevant key stakeholders including the Community and District Nursing Insulin Programme (CADNIP/) and Getting It Right First-Time representation.

Delivery will focus on collating and synthesising existing good practice of models from across the country rather than commissioning new work.

The established Community Nursing Clinical Reference Group and Community Nursing Fellows Alumni will support sense-checking and identification of exemplar models.

The output will be the development of a principles document which will set out guidance to support integrated care boards and community providers with service models that empower and support people to manage insulin in community settings.

In view of other relevant HSSIB recommendations related to supporting safe self-administration for patients in the community, for example for patients with a mental health problem, we will collaborate with other stakeholders to ensure strategic alignment and integration of related work to maximise impact and reduce risk of any duplication.

Actions planned to deliver safety recommendation:

Establish a short life task and finish group, by October 2026. Resources in place: This will be delivered by the Community Nursing and Primary Care Nursing Team, NHS England. Other dependencies identified: Strategic alignment and integration of related work with colleagues responsible for other HSSIB recommendations related to insulin in community.
Collate and synthesise existing good practice, by June 2027.
Develop and draft principles document providing guidance, by October 2027.
Test the draft principles with several community providers prior to finalising and publication, by December 2027.
Finalise the principles document, obtain internal sign-off incorporating output of recommendation 085, by March 2028.

Response received on 14 July 2026.

NHS England |

Department of Health and Social Care

HSSIB recommends that NHS England/Department of Health and Social Care develops a tool for use in community settings to support the assessment of competency of patients, their families and carers to manage and administer insulin and care for people with diabetes. This should include recognition of a person’s circumstances, the impact of disabilities and impairments, and potential adjustments to support administration where safe to do so. This is to support consistency in how competency is assessed for the safe management of insulin within the context of modern diabetes care.

This recommendation will be overseen by the short life task and finish group, established to oversee delivery of both recommendations.

Delivery will draw on existing frameworks and examples of best practice from professional bodies, diabetes charities and community providers, adapted, used, and endorsed rather than built from scratch.

Patient, family and carer engagement and voice will be incorporated through existing stakeholder engagement mechanisms rather than separately commissioned co-production.

The output will be a tool for use in community settings which will be incorporated into guidance and tested through the Clinical Reference Group.

Actions planned to deliver safety recommendation:

Establish a short life task and finish group, by October 2026. Resources in place: This will be delivered by the Community Nursing and Primary Care Nursing Team, NHS England. Other dependencies identified: Strategic alignment and integration of related work with colleagues responsible for other HSSIB recommendations related to insulin in community.
Develop and test the tool through short life task and finish group, key stakeholders, and community providers, by October - December 2027.
Incorporate patient, family, and carer voice through existing stakeholder engagement mechanisms.
Finalise the tool and incorporate into guidance recommendation 084, obtain internal sign-off and publish, by March 2028.

Response received on 14 July 2026.

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, assesses the feasibility of research, and supports its commissioning, to address the gaps in knowledge around services, device and technology requirements for support of people with a learning disability to self-administer insulin for diabetes. This should be undertaken through co-development with people with a learning disability and aim to create new knowledge to inform delivery of safe and effective care for this group of patients.

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.

National bodies can improve patient safety by providing clarity on expectations around 1) how staff recognise that a patient’s mental capacity may be compromised in relation to decisions about their self-management of insulin, and 2) the undertaking of a mental capacity assessment by the most appropriate person. This should include clarification on the practical application of the Mental Capacity Act (2005) to situations where a patient’s capacity may fluctuate and where sharing confidential information to support patient safety may be appropriate.

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

Jump to:

Background

Summary of investigation

Investigation reports

Publications

Downloads

Safety recommendations

NHS England |

Department of Health and Social Care

National Institute for Health and Care Research

Royal College of Psychiatrists

NHS England |

Department of Health and Social Care

NHS England |

Department of Health and Social Care

National Institute for Health and Care Research

Safety observations