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Insulin

Thirlwall Inquiry · Thirlwall Inquiry Final Report · Issued 15 September 2026

Government responseDepartment of Health and Social Care: Accepted (Sep 2026)

DeliveryDepartment of Health and Social Care says in progress (Sep 2026)

Recommendation, verbatim from the inquiry

●Inquiry recommendation, Chapter 34

i. Digital devices should be used to restrict access of insulin to authorised people
and record access to insulin storage units. I acknowledge that steps are being taken to
achieve this. By 31 March 2027, all neonatal units must meet the expected requirements
for access control and storage of insulin set out in the NHS England Getting It Right First
Time guide, GIRFT Neonatology: Guide to safe insulin use.
ii. Until access to insulin requires the provision of biometric data, each Trust should install
CCTV cameras focused on storage fridges, cupboards or units. The cameras should store
recordings for at least 28 days.
iii. The GIRFT Laboratory Handling of Insulin Requests in the Investigation of Hypoglycaemia
guidance for the testing and reporting of insulin and C-peptide results, issued in October
2025, must be made mandatory and of national application.

Thirlwall Inquiry, Thirlwall Inquiry Final Report · 15 Sep 2026 Source PDF, page 1 →

Published evidence summary

AI-generated evidence summary

In September 2026, the Department of Health and Social Care accepted the recommendation, with the Secretary of State, Yvette Cooper, stating that the government agreed to introduce stronger controls on insulin storage while beginning work on safe storage guidance (Yvette Cooper response, Sep 2026; Department of Health and Social Care, Sep 2026). Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer, instructed trusts that same month to urgently install CCTV monitoring insulin storage by 30 November 2026 until biometric access is in place (Duncan Burton; Sarah-Jane Marsh, Sep 2026). Under their directive, all neonatal units must meet required access control and storage standards by 31 March 2027 (Duncan Burton; Sarah-Jane Marsh, Sep 2026).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

Government response

●Department of Health and Social Care · Accepted · 15 Sep 2026

Words of: Yvette Cooper, Secretary of State for Health and Social Care, oral statement to the House of Commons, 15 September 2026 (text as published on GOV.UK)

It recommends much stronger controls on insulin storage. The NHS has begun that process with new guidance in January of this year, but we agree with the recommendation to go further.

Extract from: Government response to the Thirlwall Inquiry

Delivery

●Department of Health and Social Care says in progress · 15 Sep 2026

new guidance on the safe use and storage of insulin and strengthened guidance for medical examiners reviewing neonatal deaths

From: Government to act on Thirlwall patient safety recommendations

Site note: Department of Health and Social Care press release of 15 September 2026. The passage is one item in a list of measures the government says it has begun "while it considers the inquiry's recommendations in full"; the release does not number the recommendations. The release gives this item once, for insulin (recommendation 2) and medical examiners (recommendation 11) together, and the same words are recorded on each.

What other bodies have found

In their own words. These do not change the delivery statement above.

●NHS England · 22 Sep 2026

Insulin: By 31 March 2027, all neonatal units must meet requirements for access control and storage of insulin as set out in the GIRFT neonatology guide to safe insulin use. Until access to insulin requires the provision of biometric data, each trust should urgently install CCTV cameras in neonatal units focused on storage fridges, cupboards or units by 30 November 2026 at the latest. The cameras should store recordings for at least 28 days.

From: Thirlwall Inquiry report and recommendations (letter PRN02660)

Site note: NHS England's letter to NHS trusts and integrated care boards (PRN02660), signed by Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer. The letter bears no date; NHS England published it on 22 September 2026, and it calls the leadership event of 22 September "tomorrow". The passage is under the letter's heading "Actions needed now".

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.