HSSIB investigation report. Medication not given: discharge from an acute hospital to the community (14 August 2025)

Summary

This is the third in a series of Health Services Safety Investigations Body (HSSIB) investigations exploring why medications intended to be given to patients were not given. Patients who need medications can suffer harm if they are not given. 

This investigation explored the systems and processes in place to support staff when a patient spends time in hospital and is then discharged into the community with medications. The investigation also explored the role played by electronic prescribing and medicines administration (ePMA) systems and electronic patient record (EPR) systems in supporting care in this area.

To examine these issues, the investigation explored a patient safety event involving a man aged 53 years who was discharged from hospital to his home. He had type 2 diabetes and used medications to manage his blood glucose levels.

Content

The patient safety event

On day 1, the patient was admitted to an acute hospital following a fall at home. During his time in hospital, a change was made to his diabetes medication regimen from metformin (one form of medication used to treat diabetes) to insulin (a hormone that helps the body to use glucose for energy). On day 4, education was provided to the patient in hospital to support him to administer his own insulin (self-administer) after discharge. On day 7, the patient was discharged home. District nursing support was arranged for wound and catheter (a tube used to drain urine from the bladder) care.

On day 13, 6 days after discharge, the patient had a follow-up call with the hospital diabetes team. The patient told the diabetes team he was unable to remember all of the information about his insulin medication and he had not been self-administering. The diabetes team referred the patient via his GP for district nursing support to help with this. The district nursing team continued visits to the patient for wound care but were unaware a referral from the GP for insulin support was awaited.

On day 22, 17 days after the patient was discharged, the district nursing team visited the patient out of hours for a catheter issue. During this visit, the patient disclosed he had not taken any insulin since leaving hospital. The patient’s blood glucose reading was high and a decision was made to re-admit him to hospital because of this. He was taken to the hospital by ambulance, stayed overnight for observation and was discharged the following day.

Findings

• On the patient’s admission, conflicting information in his patient records created challenges for staff in understanding whether he was taking any medication to manage his diabetes.
• The patient’s individual circumstances were considered by the hospital diabetes specialist nursing team when arranging education for self-administering his insulin. However, there was no documentation available to establish whether the patient was able to effectively self-administer his insulin after the education and manage his diabetes during the rest of his inpatient stay.
• The patient’s need for district nursing support for insulin administration was understood and documented differently by different hospital teams, and between hospital and district nursing teams. The patient received support for wound care only and did not receive support in administering insulin after being discharged.
• The processes for managing medications on the ward and in the hospital’s discharge lounge did not identify that the patient was discharged home with two different insulin pens, including one he did not need. This resulted in confusion for the patient about which one he should use.
• Post-discharge, follow-up processes from the hospital diabetes specialist nursing team identified that the patient was not taking his insulin; this provided an opportunity for further support to be arranged.
• Unlike hospital ward staff, the hospital diabetes nurse specialist service could not refer the patient directly to the district nursing service to arrange support. Instead, they had to contact the GP for a referral to be made. This delayed the patient receiving insulin support in the community.
• A mismatch between demand and capacity within the district nursing service often led to visits being overscheduled and time restrictions during patient visits. This limited the wider interaction staff could have with patients outside of the specific focus of their visit.
• District nursing services identified that the patient was not taking his insulin by chance during a routine wound care visit before any additional referral for insulin support, to district nursing services could be made by the GP practice.
• Due to commissioning arrangements, there was an inequity in the availability of post-discharge specialist diabetes nursing support in the community that could be offered to the patients in the region, resulting in this patient not being able to access a specialist community diabetes service.
• Multiple healthcare providers were involved with the patient’s care. They used different electronic patient record (EPR) systems that did not interact to share information about the patient’s care and referral status.

Local-level learning prompts

The following prompts are provided by HSSIB to help organisations improve the safety of patients who need insulin and are being discharged from an acute hospital to the community.

Care in hospital

• How does your organisation support staff to quickly and easily identify what medication a patient is currently taking and their medication history?
• How does your organisation make sure that patients have access to specialist diabetes support including out of hours?
• How does your organisation support staff to gain an understanding of the care patients with diabetes need?
• How does your organisation ensure that education given to patients emphasises the importance of taking insulin and is appropriate and tailored to their individual needs?
• How does your organisation support patients to feel confident and safe in self-administration of insulin?
• How does your organisation support patients to understand how to raise concerns about self-administration of insulin?
• How does your organisation consider family, carer or living arrangements when providing education on self-administration?
• How does your organisation support staff to ensure that medications for an individual patient that are no longer needed are disposed of safely?

Planning for discharge in hospital

• How does your organisation support staff to complete medication checks before patients are discharged home with medications?
• How does your organisation follow up with patients post discharge, whose insulin regimen has started or been changed while in hospital?
• How does your organisation work with other services to help provide co-ordinated care for patients discharged home who need insulin support?
• How does your organisation support staff to identify and be able to refer to local diabetes specialist services when patients are discharged home?
• Does your organisation support staff to make timely and effective referrals to district nursing services to support insulin administration?

Care in the community

• How does your organisation enable staff to understand that a patient referral has been received, actioned, and completed?
• How does your organisation ensure enough time is allocated to district nursing visits based on individual patient needs?
• How does your organisation support staff to take rest breaks and reduce the risk of staff fatigue?