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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 Service Safety Investigations Body (HSSIB) investigation focuses on how the health needs of people in prison are assessed and the provision of safe living conditions for people in prison who use a wheelchair or have mobility issues. This investigation explored how healthcare provision for a whole prison’s population is assessed and commissioned using health needs assessments. How outdated assessments may present a patient safety risk through mismatched staffing skill mix and services that don’t match the patient’s needs. These risks may result in physical injuries, psychological distress and dignity violations, each of which can impact on patient wellbeing. It looked at challenges related to this approach, cost implications of the current system and ongoing developments. Disability access within prisons is complicated by the original design and purpose of prison buildings. Some of the prison estate dates back as far as 1800, making adaptations and provision for wheelchair users, for example, difficult. The investigation explored the prevalence of this issue, the impact on people in prison and potential areas for improvement. Findings The investigation explored two main themes: health needs assessments and access for physically disabled people within prisons. These themes were identified during the evidence gathering phase for the three previous HSSIB reports in this series. The findings have been separated into these two themes and are listed below: Health needs assessments (HNAs) The current process of developing an HNA for a prison population, which are generally conducted at most every 3 years, means that HNAs are frequently out of date by the time they inform commissioning decisions. There is often a delay in prison healthcare providers being made aware of likely changes to the prison population by HM Prison and Probation Service (HMPPS). This can impact on providers’ ability to ensure the required healthcare provision is in place to serve the new population. Outdated HNAs lead to mismatched healthcare provision, forcing providers to submit business cases for additional services or absorb the financial impact of changes to their services. The business case processes were slow and did not support the needs of a rapidly changing prison population, resulting in services that may pose patient safety risks due to mismatched healthcare services, incorrect staff skill mix requiring retraining, recruitment, and removal/addition of new services. HNAs were commissioned by NHS England regional commissioning teams and did not include social care requirements as this is commissioned by local authorities, which made planning and provision of social care difficult and often resulted in delays in care. In response to limitations in the current HNA process, some regions had introduced alternative approaches, including digital data dashboards and artificial‑intelligence‑enabled tools. Different approaches to assessing healthcare requirements for prison populations contributed to variation in how healthcare services were commissioned and delivered across the prison estate. Stakeholder engagement in assessing prison population health requirements was limited; local authorities and other relevant bodies were rarely consulted, contrary to guidance. Physical disability access Wheelchair users experienced harm and dignity concerns, including injuries from unsafe chair-to-chair transfers and deteriorating mental health caused by being housed in inappropriate accommodation. The number of wheelchair users in prisons is increasing, and many prisons cannot easily accommodate wheelchair users or people with mobility issues. None of the prisons visited had enough wheelchair-accessible cells. In some regions there were none. Accessible cells are sometimes located only on vulnerable prisoner wings, potentially wrongly associating wheelchair users with that cohort of prisoners. The current system for gathering information on the physical accommodation needs of people in prison is ineffective; this can impact on the ability to place people in appropriate accommodation. HSSIB makes the following safety recommendations HSSIB recommends that HM Prison and Probation Service, in collaboration with the Department of Health and Social Care, formalises arrangements for alerting healthcare commissioners and providers to changes in prison populations likely to impact on healthcare provision requirements. This is to ensure that healthcare commissioners and providers can plan for changes to healthcare services that are necessary to meet the changing needs of the prison population. HSSIB recommends that the Department of Health and Social Care works with local authorities to redesign how the health and social care needs of prisons’ populations are assessed. This is to ensure that appropriate services are commissioned to meet the needs of people in prison and prevent possible delays in care. HSSIB recommends that HM Prison and Probation Service reviews and amends its information gathering processes for accommodation requirements for wheelchair users and people with mobility issues, to identify and mitigate risks for people whose accommodation does not meet their needs. This is to enable and support the effective identification of appropriate prison accommodation for these groups.

The final module in the long-running Covid-19 inquiry has concluded, marking the end of public hearings that began almost three years ago. While other sections of the inquiry have focused on specific areas of the pandemic, such as the care sector, economy, vaccines and political decision-making, module 10 had a broader remit, looking at the overall impact on society and the legacy left behind. “This module is about making a permanent record of the impact of Covid-19, lest people forget, and about recommending improvements for the future,” said Heather Hallett, the inquiry chair, at its outset. This Guardian article highlights some of the key things we learned: Related reading on the hub: "Why should a vulnerable person be expected to tolerate lack of protections against Covid?" Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn

This report presents the findings of Healthcare Inspectorate Wales (HIW) from inspections of mental health and learning disability services across Wales between April 2024 and March 2025. During this period, HIW undertook 25 onsite inspections across NHS and independent hospitals, as well as community mental health teams (CMHTs), to assess the quality, safety, and effectiveness of care provided. Of the 25 inspections conducted, 14 were of NHS hospitals and 11 were of independent providers. This total includes two separate inspections of the same independent provider.

This report sets out why Mencap believe there is institutional discrimination within the NHS, and why people with a learning disability get worse healthcare than non-disabled people. They present the stories of six people who they believe have died unnecessarily. They do so because they argue that healthcare professionals need to realise the serious – even fatal – consequences of their lack of understanding. They call for professionals to work to ensure that such tragedies can never happen again

In this report, Carer's UK examine the benefits of moving to paid Carer’s Leave, including the positive impact it would have for women and lower paid workers. They also outline the anticipated costs and savings this would result in for HM Treasury.

Drawing on The King’s Fund’s five-year programme of work on health inequalities and tackling the worst health outcomes, which includes insights from stakeholders, partners and people with lived experience, this long read outlines what the King's Fund think the anticipated 10-year health plan should focus on to help the NHS do more to tackle these challenges. It includes a video from Stella O'Brien describing the barriers she has faced when accessing health and care services as a deaf person, and the importance of recognising patients and carers as assets. Seven priorities for the new 10-year health plan: Develop a cross-government health inequalities strategy for the 10-year health plan to feed into. Reorientate the NHS to focus on prevention. Radically change the relationships the NHS has with people and communities, from ‘power over’ to ‘power with’. Tackle racism and discrimination in the NHS and cultivate a culture of compassion. Enable staff to identify and act on health inequalities and capture learning. Empower place-based partnerships to take more decisions about how NHS money is spent. Actively support local voluntary, community and social enterprise (VCSE) organisations through changes in financial planning and commissioning.

Research by NatCen for the Department for Transport, into the 3 factors linking transport, health and wellbeing: access to health services, particularly for vulnerable groups including older people how modes of transport affect physical and mental health transport as a facilitator for social interactions and social inclusion Transport can have both positive and negative impacts on health, and these impacts are experienced differently by different groups in society.

This is one of a series of 'Learning from safety incidents' resources published by the Care Quality Commission (CQC). Each one briefly describes a critical issue—what happened, what the CQC and the provider have done about it, and the steps you can take to avoid it happening in your service. This edition is about ensuring the safety of people using wheelchairs in health and social care. The CQC recently prosecuted a care home provider for exposing someone using their service to a significant risk of avoidable harm, which resulted in a life-changing injury. Incident Before the incident, the person had been experiencing difficulties with mobility and had sometimes been confused and agitated. They had been provided with an adapted wheelchair with extended footplates for their own use, and staff helped them get around in it. However, staff mainly used a standard wheelchair for communal use within the care home. On several occasions, the person's foot had come away from the footplate when using a standard wheelchair, resulting in a risk of it getting trapped. On the day of the incident, while pushing the person down a slope in a standard wheelchair, the staff member noticed resistance and found the person's foot caught underneath. The staff member replaced the person's foot on the footplate and continued the journey. Afterwards, the person complained about pain in the affected leg and was taken to hospital for further assessment. The person was found to have significant, life-changing fractures to their leg and, at one stage, it was thought it may have to be amputated. The person spent 16 weeks in bed with their leg in a cast, before being discharged from hospital to a different service. Unfortunately, they did not make a full recovery and their physical health was permanently affected by the incident. The CQC's investigation found that, although the provider knew the risks associated with the use of a communal wheelchair, the care home failed to take adequate steps to assess and mitigate those risks. Recommendations To manage the risk of injuries to people from wheelchairs, health and social care providers need to: develop and implement adequate moving and handling plans develop and implement a risk assessment specific to a person's use of a wheelchair have adequate policies and procedures to support staff in managing these risks assess a person's mental capacity to decide about using a wheelchair, especially one not provided specifically for them provide staff with the training, skills and knowledge required to safely use a wheelchair seek the support of other professionals, such as occupational therapists, where required.

There is a well-established case for involving communities and people with lived experience in health and care policy, service design and delivery. NHS England guidance on working in partnership with communities highlights the financial benefits and improvements to quality and health outcomes that working with local communities brings. But could this involvement go further? In this article, Loreen Chikwira, Researcher at The King's Fund looks at the arguments for the use of intersectional approaches in understanding people’s lived experience of care in tackling ethnic health inequalities. These intersectional approaches help health and care providers shift their focus from people’s behaviours to also identifying and addressing ways of working that create and reinforce inequalities and poor experiences of care.

This study looked at nursing within the UK and The Netherlands' health sectors, which are both highly regulated with policies to increase inclusiveness. It aimed to investigate the interplay between employment conditions and policy measures at sectoral level, in order to identify how these both facilitate and limit employment participation for disabled workers.

The Safe Care at Home Review is an important reminder that people with care and support needs may experience abuse and neglect, sometimes under the guise of ‘care’. Older people, or people with disabilities, may be particularly vulnerable to harm because of their dependence on others and the complexity of their care needs. They might rely on other people for physical, mental or financial support, and may face difficulties recognising or reporting harm. The review draws on a range of evidence, including the Home Office funded Vulnerability Knowledge and Practice Programme, which has highlighted that one in six domestic homicides involved people who were cared for by, or caring for, the suspect.

This national data collection project has been commissioned by NHS England (NHSE) and is run by the NHS Benchmarking Network (NHSBN). The aim of the project is to understand the extent to which organisations are complying with the NHSE Learning Disability Improvement Standards, and to identify improvement opportunities. Compliance with these standards requires organisations to assure themselves that they have the necessary structures, processes, workforce and skills to deliver the outcomes that people with learning disabilities and their families and carers, expect and deserve. This project aims to collect data from a number of perspectives to understand the overall quality of care across Learning Disability services. Read summary reports from previous years of the NHS England Learning Disability Improvement Standards project.

New research showed how a national quality improvement programme called PReCePT (Preventing Cerebral Palsy in Pre Term labour) accelerated maternity units’ use of Magnesium sulphate for pre-term labour. The programme could serve as a blueprint for future efforts to get clinical guidelines into practice in other areas of care. The quality improvement programme involved training staff on the benefits of magnesium sulphate, and having a local midwife dedicated to encouraging and monitoring use of the medicine at their maternity unit. The programme was supported by Academic Health Science Networks (a regional and national organisation that encourages improvement and innovation in healthcare).  This article from the National Institute for Health and Care Research provides a plain English summary and short film about the project.

Getting a GP appointment is often a challenge at the moment, but for many disabled people, access to their GP has long been a problem. The King's Fund explored disabled people’s experiences of involvement in health and care design, their experiences accessing health and care, as well as of involvement in service design. Some participants described the significant difference a GP could make: those who made someone feel listened to and validated, compared with GPs who dismissed concerns or spoke to a person’s personal assistants rather than directly to them.  

This study in the Journal of Applied Research in Intellectual Disabilities aimed to  share rich detail of the emotional and physical impact on children and young people with intellectual disabilities of attending hospital, from their own and their parent's perspective. The authors found that the multiple and compounding layers of complexity surrounding hospital care of children and young people with intellectual disabilities resulted in challenges associated with loss of familiarity and routine, undergoing procedures, managing sensory overload, managing pain and having a lack of safety awareness. They concluded that an individualised approach to care is needed to overcome these issues.