A new report from the 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, patient deaths.
The report highlights that hospital inpatients with diabetes have been injured or have died because their insulin was not managed correctly, despite insulin being recognised as one of the NHS’s highest‑risk medications. As diabetes prevalence continues to rise across England, the investigation warns that risks linked to inpatient insulin administration could increase further unless systemic improvements are made.
The investigation, drawing on interviews with patients, families, carers, NHS staff and serious incident reports, identified a series of 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 following the removal of wearable diabetes technology, with clinicians failing to manage glucose levels effectively.
The report reveals that such failures can disrupt patients’ established routines and heighten the risk of insulin being omitted, delayed or administered improperly.
The investigation found that approximately 1 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 investigation warns that these combined pressures can create “safety blind spots,” making it difficult for organisations to spot patterns, recognise deteriorating patients and implement timely improvements.
The report also found inconsistent reporting and oversight of inpatient diabetes safety at local, system and national levels. This fragmented picture makes coordinated improvement challenging and reduces opportunities for learning, particularly around recurring harm linked to insulin management.
Inpatient diabetes teams, described as essential to improving outcomes, are often stretched thin and not available out of hours, leaving non‑specialist staff to manage complex conditions without the full support they need.
The investigation issues several safety recommendations aimed at:
- Strengthening regulatory activity relating to inpatient diabetes care
- Improving national oversight and assurance mechanisms
- Enhancing systems to recognise and respond to deteriorating patients, particularly relating to blood glucose levels
It also includes Safety learning for Integrated Care Boards, local learning prompts for NHS trusts, and guidance to help organisations reduce the risks identified.
These recommendations aim to ensure safer insulin management, earlier recognition of harm risks, and stronger consistency in care across hospitals.
Senior Safety Investigator at the HSSIB, Craig Hadley, said:
“Our investigation shows that, despite the dedication of hospital teams, patients with diabetes who rely on insulin still face persistent and avoidable risks when they come into hospital. When insulin management is disrupted – even briefly – the consequences can be serious as we heard from patients and families who shared their distressing experiences of harm, to themselves or their loved ones.
“The investigation reveals a system under strain, creating difficult conditions that can hinder the safe administration of insulin for inpatients. People with diabetes are typically able to manage their insulin independently, yet this is often reduced or removed in hospital settings. Responsibility then shifts to staff who may lack specialist expertise, but they do not always have reliable access to specialist inpatient teams, which are stretched and not consistently available.
“As the prevalence of diabetes continues to rise, the wider health and care system must acknowledge the rising risks and their impact on people receiving hospital care. Our findings and recommendations set out clear actions to reduce these risks and strengthen consistency, accountability, and oversight. Patients should be able to trust that when they come into hospital, the management of their insulin will remain safe, reliable and responsive to their needs.”
The report concludes that without urgent action to support patient self‑management, boost staff training, improve oversight and strengthen specialist services, the safety risks facing people with diabetes in hospital will continue. It urges local, regional and national leaders to work together to close the safety gaps that are currently putting thousands of patients at avoidable risk.
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