Source · HSSIB Patient Safety Investigation
Insulin: supporting safe self-administration for patients in the community with a mental health problem
Published 26 February 2026
Published
Mental health
Medication
Learning disabilities
This investigation explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of harm because of their circumstances. We have also launched an investigation to examine risks to patient safety when patients who take insulin are admitted to acute hospitals.
Summary
3 recommendations
2 observations
1 of 3 responded
Safety Recommendations
R/2026/073
NHS England/Department of Health and Social Care
HSSIB recommends that NHS England/Department of Health and Social Care develops a strategy for improving collaboration between mental health teams and specialist diabetes services, that includes consideration of responsibilities for integrated working at national, regional and local levels. This is to support future integration of services that will benefit all patients with mental health and diabetes care needs, including patients who are required to self-administer insulin and patients with type 1 diabetes and disordered eating.
No response published on HSSIB's website
R/2026/074
National Institute for Health and Care Research
HSSIB recommends that the National Institute for Health and Care Research, in collaboration with relevant research and policy stakeholders:
1) maps the knowledge gaps surrounding type 1 diabetes and disordered eating (including those identified in this investigation); and
2) assesses the priority and feasibility of commissioning research to help address those gaps.
This is to help develop new knowledge to inform future decisions for the delivery of safe and effective care for this group of patients.
No response published on HSSIB's website
R/2026/075
Royal College of Psychiatrists
HSSIB recommends that Royal College of Psychiatrists, through collaboration with relevant stakeholders, develops a strategy that:
1) supports consistent recognition of patients with type 1 diabetes and evidence of disordered eating; and
2) identifies associated care responsibilities for providers of mental and physical health services.
This is to help improve the NHS’s recognition of patients who are affected and to support decisions around the commissioning of services.
The Royal College of Psychiatrists supports the recommendation in principle but states it currently lacks the capacity to undertake the work. The matter will be kept under review for future consideration.
Response received 27 April 2026
The Royal College of Psychiatrists support this recommendation in principle. Currently the College does not have the capacity to undertake the work involved. This will be kept under review and will be considered further should an opportunity become available. Response received on 27 April 2026.
Safety Observations
Observation 1
Observation
Organisations involved in the provision of undergraduate and pre-registration education and preceptorship/induction programmes can improve patient safety by ensuring that staff have knowledge of diabetes, an understanding of how and why insulin is a vital treatment for many people with diabetes, and the risks that the use and misuse of insulin can present for patients with a mental health problem.
Observation 2
Observation
Organisations involved in the manufacture of insulin pen devices used by the NHS can improve patient safety by:
1) understanding where devices are being used outside of their intended purpose; and
2) exploring the potential to design devices that would reduce the risk of intentional overdose of insulin for self-harm.
HSSIB suggests safety learning for integrated care boards
HSSIB investigations include safety learning for integrated care boards where this may support the response to a patient safety issue across a geographical footprint.
Safety learning for integrated care boards ICB/2026/014:
HSSIB suggests that integrated care boards formalise collaborations between mental health and specialist diabetes services in their local systems. Through co-production with people with lived experience, this should look to include:
care arrangements for people with a mental health problem and diabetes, particularly for those who require insulin
routes for community mental health teams to access advice where their patients have diabetes and access to insulin
routes for diabetes specialist teams to seek advice from mental health teams about reasonable adjustments for patients under the care of outpatient clinics
enablement of interoperability between electronic systems to support information sharing.
Safety learning for integrated care boards ICB/2026/015:
HSSIB suggests that integrated care boards develop data-driven approaches for the understanding of local need to inform decisions about services for patients who have been identified as marginalised in this investigation. These are patients with:
1) co-existing mental health and long-term physical health needs (diabetes), including those with a diagnosed personality disorder and/or experiencing homelessness; and
2) type 1 diabetes and disordered eating.