A report from Britain’s Health Services Safety Investigations Body has uncovered persistent and significant safety risks facing patients with insulin‑dependent diabetes when they are admitted to hospital, with failings contributing to avoidable harm and, in some cases, even deaths, reports the UK National Health Executive.
The report highlights that patients have been injured or died because their insulin was not managed correctly, despite being recognised as one of the National Health Service’s highest‑risk medications. The investigation warns that risks linked to inpatient insulin administration could increase further unless systemic improvements are made.
Drawing on interviews with patients, families, carers, NHS staff and serious incident reports, the probe identified various concerning failures, including:
• Insulin infusions stopped before surgery and were never restarted, contributing to the patient’s death.
• Insulin was administered after meals instead of before, again contributing to a fatal outcome, with staff reporting this error continued “occasionally” in subsequent cases.
• Incorrect insulin doses are being given, including dangerously high amounts, leading to a patient’s death.
• Harm caused when patients were prevented from self‑managing their insulin, despite safely doing so at home.
• Incorrect care after the removal of wearable diabetes technology, with clinicians failing to manage glucose levels effectively.
The investigation found that one in 25 hospital inpatients with type 1 diabetes develop diabetic ketoacidosis (DKA) because their insulin is missed or insufficient for their clinical condition – a stark indication of wide‑ranging systemic issues.
Contributing factors include:
• Inconsistent support for patients to self‑administer insulin in the hospital
• Variability in staff confidence and skills among non‑specialists
• Under‑resourced inpatient diabetes teams
• Lack of seven‑day diabetes specialist cover
• National early‑warning systems (such as NEWS2) not accounting for blood glucose readings
The report also found inconsistent reporting and oversight of inpatient diabetes safety at local, system and national levels, as well as Inpatient diabetes teams often being stretched thin and not available after-hours, leaving non‑specialist staff to manage complex conditions.
The investigation issues several safety recommendations to strengthen regulatory activity, including improving oversight and assurance mechanisms, enhancing systems to recognise and respond to deteriorating patients, particularly relating to blood glucose levels, and safety learning for Integrated Care Boards, among other measures.
The report also urged local, regional and national leaders to work together to close the safety gaps putting thousands of patients at avoidable risk.
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26,000 NHS diabetic medication errors due to lack of specialist staff
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