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Virtual wards, also known as hospital at home, are increasingly being used across the NHS to support people who would otherwise need hospital care to receive treatment and monitoring at home. A new NIHR-funded study led by University of Manchester researchers explored how safe care is delivered in virtual wards, highlighting the often unseen work carried out by patients and carers as they undertake key elements of risk-work previously held by clinicians. The findings show that virtual wards can provide a safe alternative to hospital care for some patients, allowing people to recover at home while still receiving clinical oversight. However, patients and carers often take on more practical and emotional responsibility than may be recognised as they assume duties that would normally be carried out by clinicians in hospital settings. This includes monitoring symptoms, managing equipment and responding to signs of deterioration, especially overnight or outside normal working hours. The researchers suggest that hospital at home services that combine technology with in‑person home visits could help make care safer, more flexible, and accessible for a wider range of patients. Recognising and supporting the work undertaken by patients and carers is essential to ensure virtual wards are safely delivered. As virtual wards expand as a key component of NHS policy to shift acute care from hospital to community settings, practice must ensure there is space for relational and training support for clinicians, patients, and carers so that remote acute care can be safely implemented across health systems.

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 study, published in JAMA Network Open, considered how often and what types of patient safety events are reported by paediatric home health care staff. Researchers undertook a multistate cohort study of paediatric home health care data of 2,901 children, more than 1 in 10 children had an incident reported by agency staff. In this cohort it found that more than 1 in 10 had a reported incident, of which approximately half were patient safety related. This work provides new data about paediatric home health safety, with the authors suggesting that further work should explore factors contributing to and preventing health care related harms to children at home and include parent perspectives.

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

On 27 March 2024 an investigation took place into the death of Sewa Kaur Chaddha, then aged 82. Mrs Chaddha had been living with her husband in Slough. They both had a number of physical health conditions requiring multiple prescribed medications. They both had cognitive impairment due to their age. On 5 May 2023 Mrs Chaddha was found collapsed on the floor at their home. It was discovered that she had been taking her husbands medication instead of her own for several days, including diabetes medication. Her blood sugar levels were found to be extremely low. She died on 10 May 2023 at Wexham Park Hospital of hyponatraemia caused by the necessary treatment for hypoglycaemia which was in turn caused by the accidental ingestion of hypoglycaemic medication. The investigation concluded at the end of the inquest on 24 May 2024. The conclusion of the inquest was accident, the medical cause of death being: I a Hyponatraemia I b Treatment for hypoglycaemia I c Ingestion of hypoglycaemic medication II Frailty of old age, decompensated heart failure, cognitive impairment. Matters of Concerns The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis. Both patients were elderly and had cognitive impairment. (The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name. Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days. Evidence was given at the inquest that there was no guidance or policy in place for Pharmacists to follow when issuing medication to patients with cognitive impairments, or if there was, it was not well disseminated among the pharmacist population. Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address.