Insulin: supporting safe self-administration for patients in the community with a mental health problem (HSSIB, 26 February 2026)

Summary

This Health Services Safety Investigations Body (HSSIB) report is the first in a series considering the self-administration of insulin by people with diabetes mellitus (diabetes) in community settings. It focuses on adults with a mental health problem who are known to or under the care of secondary mental health services (specialist services provided in the community), who have been harmed when they have not self-administered their prescribed insulin as intended – this is referred to as the patient safety issue in this report. People have come to harm or have died as a result of self-administering too much insulin and/or not self-administering insulin when it is needed.

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

• collaboration between mental health and specialist diabetes services
• care for patients experiencing a mental health crisis
• access to insulin devices and technology.

Content

Findings

Findings related to collaboration between mental health and specialist diabetes services

• Patients with a mental health problem and diabetes (requiring treatment with insulin) in the community are not always under the care of specialist diabetes services when this would be expected in their care (for example patients with type 1 diabetes).
• Patients have been discharged from specialist diabetes services after missing one or more appointments (‘did not attend’). Patients may be discharged without consideration of their circumstances and clinical risk.
• Patients have disengaged from specialist diabetes services when adjustments have not been made for their mental health needs. Services had limited access to support from specialist mental health teams.
• Community mental health teams feel responsible for their patients’ diabetes care when they are not under the care of a specialist diabetes service. Teams have limited routes through which to access support around insulin management.
• There is variable integration of mental health and specialist diabetes services in different parts of the country. This is despite recognition of the disconnect between services and the risks to patient safety and physical health.
• Digital integration between mental health and specialist diabetes services is also variable. This has created barriers to information sharing and has contributed to patient safety incidents.
• Integrated care boards face barriers – such as resource limitations, workforce shortages and separated policy teams – to developing integrated arrangements between mental health and specialist diabetes services.
• There are unclear national plans for the long-term integration of mental health and physical health services, with limited national collaboration between relevant policy teams to address the issues.
• There continues to be no effective mechanism to allow regulatory oversight of care pathways that span different providers/organisations, such as for integrated mental health and diabetes care.
• The combination of type 1 diabetes and disordered eating (T1DE) contributes to significant patient harm. There are varying views about whether T1DE is a specific condition, and research gaps around the identification of and care for patients with T1DE.
• Long-term funding for T1DE services is at risk due to factors including their cost, highly specialist nature and concerns about limiting access to services for other people with diabetes and a mental health problem.
• People experiencing homelessness face challenges accessing the support they need for their mental health and diabetes. Limited data on the need for services influences investment, and prejudice may be a factor.

Findings related to access to insulin devices and technology

• There are no insulin pen devices designed in such a way that would prevent a patient from intentionally self-administering excess insulin.
• Limitations in data collected by manufacturers and national organisations means the patient safety issue in this investigation may not be apparent to manufacturers.
• Changes to insulin pen device design in response to patient safety issues may not be considered when the issues have arisen through use of the device outside of its intended purpose.
• Some patients may be being disadvantaged by not being considered for continuous glucose monitoring or hybrid closed loop systems due to their mental health problem.

Findings related to care for patients experiencing a mental health crisis

• Community mental health teams face barriers that prevent them from forming therapeutic relationships with patients and therefore the making of safety plans should the patient feel the urge to self-harm.
• People with a diagnosis of personality disorder face challenges accessing specialist mental health services that are able to meet their specific needs.
• Mental health teams may not fully recognise the risks of self-harm associated with access to different types of insulin. This is not consistently covered in pre-registration mental health practitioner training.
• Care planning does not always consider the safeguarding of patients who experience rapid and extreme fluctuations in their emotions and mental capacity, placing them at risk of self-harm.
• Information supportive of a patient’s safety may be withheld from their family – as a result of the patient declining sharing – without staff considering the context, and the patient's mental capacity and whether they recognise the potential benefits and risks of the decision.

HSSIB makes the following safety recommendations

Safety recommendation R/2026/073:

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.

Safety recommendation R/2026/074:

HSSIB recommends that the National Institute for Health and Care Research, in collaboration with relevant research and policy stakeholders:

1. maps the knowledge gaps surrounding type 1 diabetes and disordered eating (including those identified in this investigation)
2. 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.

Safety recommendation R/2026/075:

HSSIB recommends that Royal College of Psychiatrists, through collaboration with relevant stakeholders, develops a strategy that:

1. supports consistent recognition of patients with type 1 diabetes and evidence of disordered eating; and
2. 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.

HSSIB makes the following safety observations

Safety observation O/2026/081:

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.

Safety observation O/2026/082:

Organisations involved in the manufacture of insulin pen devices used by the NHS can improve patient safety by:

1. understanding where devices are being used outside of their intended purpose
2. exploring the potential to design devices that would reduce the risk of intentional overdose of insulin for self-harm.

HSSIB suggests safety learning for integrated care boards

HSSIB investigations include safety learning for integrated care boards where this may support the response to a patient safety issue across a geographical footprint.

Safety learning for integrated care boards ICB/2026/014:

HSSIB suggests that integrated care boards formalise collaborations between mental health and specialist diabetes services in their local systems. Through co-production with people with lived experience, this should look to include:

• care arrangements for people with a mental health problem and diabetes, particularly for those who require insulin
• routes for community mental health teams to access advice where their patients have diabetes and access to insulin
• routes for diabetes specialist teams to seek advice from mental health teams about reasonable adjustments for patients under the care of outpatient clinics
• enablement of interoperability between electronic systems to support information sharing.

Safety learning for integrated care boards ICB/2026/015:

HSSIB suggests that integrated care boards develop data-driven approaches for the understanding of local need to inform decisions about services for patients who have been identified as marginalised in this investigation. These are patients with:

1. co-existing mental health and long-term physical health needs (diabetes), including those with a diagnosed personality disorder and/or experiencing homelessness
2. type 1 diabetes and disordered eating.

Local-level learning

HSSIB investigations include local-level learning where this may help providers/organisations respond to a patient safety issue at the local level.

For organisations providing mental health and/or specialist diabetes services:

• Does your organisation have a specific job role with responsibility for cross-organisational care pathways to ensure the holistic needs of patients, including those with mental health problems and diabetes, are met?
• How does your organisation ensure information about patients is available to other providers of care when required, for example to mental health teams about a patient’s diabetes care?
• How does your organisation ensure staff are aware of their responsibilities to report incidents associated with diabetes medication and technology, including to manufacturers and the Medicines and Healthcare products Regulatory Agency?
• Does your organisation have a process for identifying and appropriately supporting patients with type 1 diabetes who also have evidence of disordered eating?

For organisations providing specialist diabetes services:

• How does your organisation ensure patients with a mental health problem are not being discharged from clinics following a ‘did not attend’ without consideration of their circumstances and risks to their safety?
• Do your staff recognise the need to make reasonable adjustments for patients, including for those with a mental health problem, to support access to care?
• Does your organisation have a liaison psychiatry service that supports inpatient and outpatient services for people with a mental health problem?
• Does your organisation have clear routes via which services can seek support from specialists in mental health if a patient is found to be experiencing a crisis?
• How does your organisation identify patients who have had recurrent admissions with diabetic ketoacidosis or hypoglycaemia, and support staff to consider whether these patient require input from mental health services?
• How does your organisation ensure patients with a mental health problem, who meet the criteria for diabetes technology, are receiving support to access it and are not being discriminated against because of their mental health problem?

For organisations providing mental health services:

• How does your organisation ensure staff working in the community have access to advice about a patient’s physical health, including specialist advice for conditions such as diabetes requiring treatment with insulin?
• How does your organisation keep staff up-to-date about the different types of insulin used in the NHS and their onset times to ensure this is considered as part of assessment of a patient’s risk of self-harm?
• How does your organisation enable staff to work therapeutically with patients to support them to develop safety plans which include consideration of the risks associated with insulin?
• How does your organisation support multidisciplinary discussion in discharge planning that recognises the circumstances a patient is being discharged into to ensure they are appropriate for their mental and physical health needs?
• How does your organisation support staff to make assessments under the Mental Capacity Act, with particular consideration of whether the patient can use and weigh information as part of their decision making?
• Does your organisation provide services that effectively meet the needs of people with rapidly fluctuating and extreme emotions, and that consider how best to support these patients when they are unable to make decisions to keep themselves safe?
• Do your staff recognise the importance of family involvement in patient care, and where the patient refuses this, do staff ensure the reasons for refusal and the potential ramifications are explored and it is appropriately revisited over time?
• How does your organisation support staff to not make assumptions about patients based on their circumstances and characteristics?