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This Health Services Safety Investigation Body (HSSIB) report is the second in a series considering the self-administration of insulin by people with diabetes mellitus (diabetes) in community settings. Many people with diabetes manage and administer their own insulin, either by injection or using a combined monitor/pump device (a hybrid closed loop system). However, a disability or impairment may affect their ability to safely manage their own insulin if they are not supported. This can lead to short-term and long-term health problems, which can be life threatening. HSSIB identified incidents where a person with diabetes or their family/carer had administered insulin incorrectly (the patient safety issue of focus). In these incidents, a disability – such as a visual or memory problem – had influenced how someone had administered insulin. The investigation explored the following areas in relation to the patient safety issue: supporting the development of people’s competency – that is, their skills, experience, knowledge and ability – to manage insulin recognising and responding when people’s circumstances change, such as deterioration in a disability assessment of people’s mental capacity to make decisions in relation to insulin. Findings People with diabetes (who require insulin) are at risk of harm through the administration of insulin when pre-existing or new disabilities/impairments have not been recognised or adjusted for. People are not always empowered to become competent to manage their insulin, with assumptions made that a person is not competent to do so because of a disability/impairment. Supporting people to safely self-manage their health, including insulin, requires integrated working across community services. Where this is limited, such as due to resource challenges or limited collaboration, people are put at risk. Efforts to empower and enable people to self-manage insulin are affected by the competing demands on, and the capacity and accessibility of the community services that provide this type of support. Designated and protected resource aimed at supporting the development of insulin self-management skills have shown benefits for patient experience and have reduced demand on community services. There is no national competency framework for the management of insulin by patients and families that supports community services to identify and make reasonable adjustments for a disability/impairment. Administration of insulin by staff in care homes (delegated administration) may reduce demand on community teams but is limited by barriers to implementation, including high turnover of care home staff. Some people with type 2 diabetes may be prescribed insulin without first optimising other diabetes treatments and/or exploring preferences. This means a person may be exposed to the risks of insulin unnecessarily. There are people with diabetes (who require insulin) whose circumstances mean they are not monitored for changes in a disability/impairment, including via long-term condition reviews in general practice. People may not engage with healthcare services to enable the regular monitoring of their condition. Engagement is affected by the ability of services to meet patient needs but may also represent other situations that require a response, such as in relation to patient safeguarding. Electronic systems in general practice may not alert users when people have not requested repeat prescriptions of insulin, removing a potential opportunity to identify patients who need support. Diabetes technology, such as insulin pen devices, are not always designed in a way that supports people to administer insulin when they have a disability/impairment, such as visual impairment or problems with dexterity. There are concerns about the future competence of the healthcare workforce to support the increasing numbers of people with hybrid closed loop systems. Healthcare workers may not identify when a patient’s mental capacity to make decisions in relation to their insulin may be compromised, meaning a more in-depth assessment in line with the Mental Capacity Act (2005) may not occur. Limited education and practical support for application of the Mental Capacity Act (2005) by healthcare staff means its principles are sometimes misunderstood. Patients with diabetes (who require insulin) and who experience fluctuations in their mental capacity, are at risk of harm when services do not proactively plan for a time when the patient may lose the ability to manage their insulin safely. HSSIB makes the following safety recommendations 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. 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. HSSIB makes the following safety observation 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. 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. HSSIB suggests that integrated care boards develop data-driven approaches to effectively identify the diversity of their populations’ characteristics and social circumstances, and use this data to support community providers to design services that empower and enable people to be involved in a patient’s care, including through supporting self-management of medications and conditions. HSSIB suggests that integrated care boards, through future planning for neighbourhood health services, include consideration of how patients who may be at greater risk of harm from insulin administration due to their specific circumstances – for example co-existing disabilities, social isolation or receiving home-delivered medications – are proactively monitored to identify changes in their circumstances. This may include using technology such as remote monitoring. 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. Informed by the findings in this report, the investigation shares the following local-level learning. How does your organisation create the conditions for staff to empower and enable patients, their families and carers – through a person-centred approach – to self-manage insulin where appropriate? How does your organisation proactively identify the varying needs of people with diabetes in its local population, and ensure these are met to enable their management of insulin? How does your organisation promote patient-centred care and facilitate self-care models that empower and enable patients, such as those with diabetes? Does your organisation allocate specific resources to support patients, families and carers to develop competency to self-manage insulin, and ensure those resources are protected to empower and enable people? How does your organisation ensure that staff supporting the development of a person’s competency have the required knowledge and skills to provide that training and education in relation to diabetes and insulin? How does your organisation support staff to identify and code a person’s disabilities/impairments that may influence their competency to self-manage insulin, and ensure these are considered and adjusted for when deciding whether a person is competent? Does your organisation have systems and processes to identify where patients have not requested their repeat medication prescription, or the frequency of the requests have changed, which may indicate changes in their circumstances? How does your organisation ensure long-term condition reviews reliably take place for patients who may be at a higher risk of deterioration due to their circumstances, for example those with multiple long-term conditions? How does your organisation identify and code patients – who may be more vulnerable to harm from insulin due to their circumstances – for increased monitoring? This may include patients who have their medications delivered to their home, who do not have family nearby, or who are housebound. Does your organisation provide practical training and guidance to support staff to consider the mental capacity of patients to make decisions around their insulin when there are concerns capacity may be compromised? Does your organisation provide practical guidance to staff to help identify when it is lawful, ethical and appropriate to share confidential information about a patient to mitigate risks to their safety, including with family members? Does your organisation have accessible routes via which staff can seek urgent support when they are concerned a patient’s mental capacity to make decisions about their self-care may be compromised, particularly in high-risk situations? How does your organisation support staff to develop ‘crisis plans’ for patients who self-manage insulin to protect their safety at a later point when their capacity to make decisions in relation to their care may change?

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. 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?

Advances in home diabetes management technologies have transformed how millions of people manage their condition outside of traditional clinical settings. Devices such as insulin pumps, continuous glucose monitors (CGMs), and integrated systems that combine the two have enabled tighter glucose control, fewer manual interventions, and greater independence for patients. Closed-loop systems, in particular, represent a major step forward—automating insulin delivery based on real-time glucose data and significantly improving quality of life. Yet as these technologies become more sophisticated and widely adopted, they also introduce new safety risks—especially when critical recall information, software updates, or safety warnings fail to reach patients and caregivers in a timely or understandable way. When recall communications break down, the consequences can be severe. This ECRI article looks at why recall communication matters more than ever, the clinical consequences of missed or misunderstood recalls and shared responsibility for improving recall communication. Further reading on the hub: Diabetes technology is life-changing, but we need to be prepared when it fails - A blog by Andrew Stroud How safe are closed loop artificial pancreas systems? Blog - When diabetes devices fail

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. The National Patient Safety Team identified an issue related to delivery of insulin via insulin pen safety engineered needle devices (SENDs). There are both active and passive SENDs available for insulin pens, which have different mechanisms of use. A recorded incident described a type 1 diabetic developing diabetic ketoacidosis (DKA) where no precipitating factors were identified other than potentially the method of insulin administration. A review of incident data revealed a theme of insulin ‘pooling’ on the skin following administration. This may occur when the needle of a passive SEND retracts during administration, due to releasing pressure too early so insulin sits on the skin. Reports describe patients developing DKA or hyperglycaemia due to delayed recognition of suboptimal insulin administration technique via some insulin pens. The insight from the review was shared with TREND for their ‘Injection Technique Matters’ resource and The Royal College of Nursing for RCN Sharp Safety Guidance. Findings were shared with the National Association of Medical Device Educators and Trainers (NAMDET) members via an article in their MDET journal to expand awareness that both passive and active insulin pen SENDs require education and training for use. The findings were also shared with clinical procurement specialists recommending that user education and training requirements are essential considerations when selecting either active or passive insulin pen SENDs, focussing on the additional needs of the temporary or transient workforce.

Although insulin is used daily by millions of people around the world, it is considered a high-alert drug that has been associated with more medication errors than any other medication type or class. One challenge in administering insulin is that it is measured in “units” rather than milliliters (mL), requiring unique insulin syringes with the appropriate markings. Using a syringe intended for other medication to administer insulin could lead to an overdose of up to 100 times the intended dose. To identify contributing factors and develop strategies to reduce the risk of wrong dose errors related to the use or selection of syringes, researchers focused on event reports submitted by Pennsylvania facilities in the USA over the last decade that involved U-100 insulin and syringe-related issues resulting in dosing errors or near misses. Some of the key takeaways of their detailed study—which encompassed 74 reports from 47 facilities—are that over a third of errors that reached the patient were serious events and among reports specifying syringe volume, 73.8% involved a 1-mL syringe. Contributing factors included using the wrong syringe due to improper syringe storage, similar cap color or packaging, and provider’s lack of experience. Variability in hospital insulin protocols and formularies was also observed. The authors encourage facilities to evaluate and standardize their existing insulin protocols and formularies, and implement the suggested safety strategies for preventing syringe-related insulin dose errors.

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. 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: maps the knowledge gaps surrounding type 1 diabetes and disordered eating (including those identified in this investigation) 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: 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. 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: understanding where devices are being used outside of their intended purpose 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: co-existing mental health and long-term physical health needs (diabetes), including those with a diagnosed personality disorder and/or experiencing homelessness 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?

This video series looks at systematic approaches to insulin safety, including: Part 1 Human Factors - A Journey of Discovery Part 2 SEIPS – The Swiss Army Knife Approach Part 3 - Summary & Applying the Learning

Diabetes can be detected at the primary healthcare level, and effective treatments lower the risk of complications. There are insufficient data on the coverage of treatment for diabetes and how it has changed. This study estimated trends from 1990 to 2022 in diabetes prevalence and treatment for 200 countries and territories. The findings showed that most countries, especially in low-income and middle-income countries, diabetes treatment has not increased at all or has not increased sufficiently in comparison with the rise in prevalence. The burden of diabetes and untreated diabetes is increasingly borne by low-income and middle-income countries. The expansion of health insurance and primary health care should be accompanied with diabetes programmes that realign and resource health services to enhance the early detection and effective treatment of diabetes.

Type 1 diabetes with disordered eating (T1DE), or diabulimia as some experts call it, is a serious eating disorder that people with type 1 diabetes can develop where the person reduces or stops taking their insulin as a way of managing their weight. The condition can be life-threatening. Although studies are limited, it’s estimated that eating disorders affect more than a third of patients with type 1 diabetes. This episode of the Healthcare Improvement podcast looks at diabulimia and a new toolkit published by SIGN, part of Healthcare Improvement Scotland, which sets out recommendations to raise awareness and provide guidance on how best to support people living with the diabulimia. Guests in this episode include: Lawrence Smith, who was diagnosed with type 1 diabetes when he was four years old and went on to develop an eating disorder in his teens. Safia Qureshi, Director of Evidence & Digital at Healthcare Improvement Scotland, who talks about the key recommendations in the toolkit. Dr Louise Johnston, Consultant and Clinical Lead on the inpatient unit for eating disorders, NHS Grampian.

Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. The Health Innovation Network in partnership with South London and Maudsley NHS Foundation Trust (SLaM) developed and piloted a diabetes audit. Following the SLaM pilot, the audit was completed by all nine London Mental Health Trusts. A diverse approach was taken to spread and adoption. This included piloting the audit within one MH Trust, refining, and then rolling out the audit to eight London Mental Health Trusts. Outcomes The audit evidenced a need to improve: Access to diabetes specialists; no Mental Health Trust had access to consultant diabetologists. Seven out of nine Trusts had no access to Diabetes Specialist Nurses. Staff and patient education; Mental Health Trusts offered no or irregular education. Policy communication e.g. 76% of mental health wards stated they did not have or did not know of their Trust’s diabetes self-management policy. Patients rated diabetes care as 3.63 out of 5. Since sharing the findings Mental Health Trusts have made improvements, these include: recruiting Diabetes Specialist Nurses and Physicians Associates. sharing self-management policies. offering educational training. creating physical health forums. The team used networking opportunities with key stakeholders such as London Diabetes Clinical Network and Diabetes Inpatient Network and the London Physical Health Leads Network and the Cavendish Square Group (Medical Directors and CEOs of all London MH Trusts) to ensure more than 7,000 stakeholders were aware of the project findings. The Health Innovation Network also produced a report and was successful in gaining both a poster and presentation at the 2023 Diabetes UK Conference which has a national and international audience. The audit revealed that improving diabetes care in mental health settings remains a priority for London Mental Health Trusts and the London Diabetes Clinical Network.

Hampshire and Isle of Wight Integrated Care System (ICS) has achieved great results in supporting access to the NHS Diabetes Prevention Programme. This case study outlines the approach taken by the ICS to improve access, what the outcomes were and key lessons learned.

The major conditions strategy is a national framework being developed by the Department of Health and Social Care (DHSC) and the Office for Health Improvement and Disparities (OHID). It will focus on six major groups of conditions: cancers cardiovascular diseases, including stroke and diabetes chronic respiratory diseases dementia mental ill health musculoskeletal disorders This briefing by NHS Confederation examines how the upcoming major conditions strategy can set the conditions to prevent, treat and manage multimorbidity in England. Key points NHS leaders have identified key levers that the major conditions strategy can use to maximise its impact on healthy life expectancy and reduce inequalities. These fall under three categories: create a healthy society, make the most of existing infrastructure and policy and implementation. The major conditions strategy will allow health services to evolve from a single-disease approach to a multimorbidity approach, which will match how patients need to use the service. Integrated care systems will provide vital infrastructure for the sharing of data, integration of services and creation of a patient-centred approach to health and care provision. A health service designed around multimorbidity would be a step-change for patients and requires a series of shifts to be made in both focus and provision.