The Health Services Safety Investigations Body (HSSIB) report found many patients with diabetes are not consistently supported to self-administer insulin during hospital stays, despite safely doing so at home.

Craig Hadley, senior safety investigator 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.'

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.

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. HSSIB identified inconsistent reporting and oversight of inpatient diabetes safety across local, system and national levels.

Staff and stakeholders also told HSSIB there were national systems to help recognise severely unwell and deteriorating patients (NEWS2 scoring) but they do not currently account for blood glucose readings.

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.