HSSIB investigation. Insulin: supporting safe administration in inpatient settings (26 March 2026)

Summary

This Health Services Safety Investigations Body (HSSIB) report considers the safe administration of insulin for people with known diabetes mellitus, who may be at risk of harm during admissions to hospital. HSSIB are undertaking a series of investigations that explore risks to patient safety for patients with diabetes in the community who self-administer insulin, and who may be at increased risk of harm because of their circumstances. While the findings of the report are about insulin and diabetes care in acute settings, they may also be applicable in other healthcare settings and for other physical long-term conditions.

Going into hospital can create risks for patients with diabetes. Patients have come to harm or died in hospital because their diabetes requiring treatment with insulin has not been appropriately managed.

Hearing and reviewing the experiences of those affected led the investigation to examine the following in relation to the patient safety issue:

• How staff are supported to monitor and care for patients with known diabetes on a hospital ward.
• How patients are supported to safely self-administer their insulin (through injections or via a pump or hybrid closed loop system), as part of a diabetes self-management regime.
• What national recommendations/observations have been made to date and the outcomes seen.
• The investigation’s findings are offered to support improvements in services for patients who are admitted to hospital and require ongoing care for their diabetes that requires insulin therapy.

Content

Findings

• Integrated care board (ICB), regional and national oversight for inpatient diabetes care is fragmented, and assurance for patient safety is devolved to individual trusts. This leads to gaps in responsibility and accountability for implementing national guidance and recommendations, and for acting on national audit data, for improvement of patient safety.
• Regulatory activity requires strengthening to effectively assess and address safety concerns relating to inpatient diabetes care.
• Local hospital oversight structures required by national guidance and recommendations, such as diabetes safety boards, are often absent. This can hamper local-level oversight and mitigation of risks, increasing risks to inpatients who have diabetes.
• Prioritisation and funding of inpatient diabetes care at the hospital and ICB level has not supported the full implementation of national guidance and recommendations.
• Participation in the National Diabetes Inpatient Safety Audit is low, limiting the ability to track trends, benchmark performance, or drive strategic and nationwide diabetes care improvements.
• Most inpatient diabetes care is delivered by non-specialists who may lack confidence and/or competence in diabetes management.
• Specialist diabetes teams are often under-resourced and unable to provide 7-day coverage to support non-specialist staff and care for patients. Even at recommended staffing levels, specialist teams cannot always see every patient who may need support.
• Diabetes/insulin awareness training for non-specialist staff and students is inconsistent. Education gaps persist at both trust and undergraduate levels, with no national minimum mandated standard for diabetes care or insulin safety education, training and competency assessments.
• Many hospital clinicians, along with national stakeholders, strongly support adding blood glucose levels to the National Early Warning Score (NEWS2) to improve the detection of diabetes-related patient deterioration, but acknowledge challenges in doing so.
• Many patients who safely self-administer insulin at home through injection, insulin pumps, or hybrid closed loop systems, are prevented from doing so in hospital. This can be due to local policies on diabetes self-management and insulin self-administration, and the reluctance of staff to allow patients to self-administer because they fear being blamed if things go wrong.
• Lack of clarity about safe bedside storage of insulin and misconceptions about the regulatory stance on this create barriers for patients to self-administer.
• Networked glucose meters can improve safety, but implementation of required hardware and software is inconsistent.
• There is limited integration between hospital networked glucose meters and electronic patient records, creating potential blind spots in inpatient diabetes care.

HSSIB makes the following safety recommendations

• Safety recommendation R/2026/076: HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement and act on improvements shared in national guidance, recommendations and audit data. It should also include how existing functions (Getting It Right First Time and the Diabetes Care Accreditation Programme), and those currently in development (new National Diabetes Audit for Inpatient Care) can be more closely aligned and utilised to help better understand and respond to challenges relating to the safety and quality of inpatient diabetes care.
• Safety recommendation R/2026/077: HSSIB recommends that the Royal College of Physicians reviews and acts on new data and outcomes of studies about adopting blood glucose into NEWS2 and shares any decisions it makes. This is to encourage understanding and support consideration of how blood glucose issues can be recognised early and escalated to mitigate harm.
• Safety recommendation R/2026/078: HSSIB recommends that the Care Quality Commission assesses how it can use data from the Diabetes Care Accreditation Programme and the new National Diabetes Audit for Inpatient Care as part of its regulatory activity. This is to ensure that known challenges in inpatient diabetes care, and knowledge of providers that do not report national diabetes audit data, are considered to provide intelligence in support of regulatory activity.

HSSIB makes the following safety observations

• Safety observation O/2026/083: Organisations and individuals involved in the provision of clinical undergraduate and pre-registration education, and trust preceptorship/induction programmes, can improve patient safety by using the findings of this report to prioritise diabetes care and insulin management education and training as appropriate.
• Safety observation O/2026/084: Professional regulators and royal colleges can improve patient safety by reviewing this report and disseminating appropriate communications to their registrants and members in relation to understanding their expectations in providing safe diabetes care.

HSSIB suggests safety learning for integrated care boards

HSSIB investigations include safety learning for integrated care boards where this may help organisations think about how to respond to a patient safety issue that relates to integrated care across a geographical footprint. Informed by the findings in this report, the investigation proposes the following safety learning.

• Safety learning for integrated care boards ICB/2026/016: HSSIB suggests that integrated care boards consider the findings of this report to inform funding prioritisation decisions for trust diabetes specialist inpatient services. This is to help support the delivery of safe inpatient diabetes care through appropriately staffed 7-day inpatient diabetes specialist services to mitigate patient harm.

Local-level learning

HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts.

Self-management of diabetes and insulin administration

• Do you have a policy that supports patients to safely self-manage their diabetes and support self-administration of insulin?
• Is your policy clear, available, and does it enable clinicians to support safe self-management and self-administration?
• Are the timing and content of meals considered in support of patients self-managing their diabetes?
• Is safe bedside storage of insulin provided to support self-administration? If not, how could this be supported?
• Are clinicians aware of national guidance and the regulatory stance regarding promotion of safe self-management of diabetes and insulin administration?

Diabetes specialist workforce and capacity

• Is your inpatient diabetes specialist team appropriately resourced to help mitigate known diabetes-related risks?
• Is your diabetes inpatient specialist team supported to operate out of hours, such as over weekends and bank holidays?

Non-specialist diabetes care

• Do you protect education and training time for diabetes training?
• Does your diabetes training ensure key risks to inpatients with diabetes are highlighted to staff?
• Do you have a diabetes specialist team that is appropriately resourced with sufficient capacity to deliver diabetes education and training?

Hospital diabetes technology

• Do you have networked glucose meters to support remote monitoring of patients with diabetes?
• Do the glucose meters in your hospital automatically upload data to electronic patient records, and does this support remote monitoring of patients? Does your inpatient diabetes specialist team access diabetes related reports/alerts daily to identify patients at risk?
• Do you provide digital tools or apps to support your non-specialist clinicians in providing safe diabetes care?

Wearable diabetes technology

• Do you have a wearable diabetes technology element in your diabetes education and training programme?
• Do you have clear and available guidance on wearable diabetes technology for your non-specialist clinicians?

Oversight and governance

• Do you participate in the Diabetes Care Accreditation Programme (DCAP)?
• Do you submit data to the National Diabetes Inpatient Safety Audit (to be superseded by the National Diabetes Audit for Inpatient Care)?
• Do you have a diabetes safety board with senior management involvement?
• Does your diabetes safety board work with your inpatient diabetes specialist team to understand key diabetes risks and issues?
• Does your diabetes safety board have the authority to agree actions and prioritise resources for their implementation?