First reported 7 Jan 2014•Latest report 12 Jun 2025
Definition
What this concern includes
Includes failures of controls specifically dedicated to diabetes care and management, including access to specialist diabetic support, monitoring of glucose or ketones, recognition and escalation of deterioration, diabetic status communication, insulin access and other clinically necessary diabetes-management arrangements.
Not included
Excludes generic staffing or out-of-hours service deficiencies unless they directly impair diabetes care and management.
Excludes failures concerning other clinical conditions or specialist services without a direct diabetes-care connection.
Excludes generic communication, training, documentation or escalation deficiencies unless they are specifically dedicated to diabetes care.
Excludes medication, wound-care or monitoring concerns where diabetes is merely incidental and the asserted unsafe condition belongs to a different named process.
Reports
14
Distinct published reports
Individual concerns
23
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
27
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care3
Adbolton Hall1
Avon and Wiltshire Mental Health Partnership NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Care Quality Commission1
Four Seasons Health Care Group1
Greater Manchester Mental Health NHS Foundation Trust1
Hinchingbrooke Hospital1
HM Prison and Probation Service1
Ministry of Justice1
National Institute for Health and Care Excellence1
NHS England1
NHS Hertfordshire and West Essex Integrated Care Board1
NHS Leicester, Leicestershire and Rutland Integrated Care Board1
Royal Free London NHS Foundation Trust1
NHS trust6
Ministerial department3
Executive non-departmental public body2
Healthcare site2
Integrated care board2
Care-home operator1
Executive agency1
Health and social care service regulator1
Health professional body1
Independent healthcare provider1
Nursing home1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Manchester South
Concerns raised6
Failure of nurses to recognise and escalate deteriorating diabetic care
Failure to provide specialist diabetes outreach cover during absence
Under-resourcing of diabetes care
Unavailability of specialist diabetes outreach nurse advice
Deficient nurse training on Type 1 Diabetes
Unavailability of additional diabetes consultant cover
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
Action
Commission and complete a diabetes-care Task and Finish Group review, producing an approved action plan.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Amend the Trust Training Needs Analysis to require diabetes training for nurses and doctors.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Design bespoke diabetes training for senior nurses covering night and out-of-hours care, and begin its delivery.
Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2015.
Action
Improve the Diabetes Microsite and increase availability of Diabetes Specialist Nurses to support diabetes management.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Implement an electronic inpatient referral form for requesting diabetes review and support across wards.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Put a sickness-cover and backfill plan in place for the specialist outreach nurse post.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Appoint an additional Diabetes Specialist Nurse and a Diabetes Practice Educator to support the whole Trust.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Provide additional consultant diabetes cover through an agency locum and a Consultant of the Week model.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Purchase and incorporate an NHS England-recommended diabetes e-learning module into the Training Needs Analysis.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Deliver bespoke diabetes-care training to nursing staff on wards M4 and A11.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Add diabetes and insulin management to mandatory three-yearly Essentials training for all staff.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Identify ward link nurses and provide specialist training so they can deliver local diabetes training.
Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A sickness-cover plan for the specialist outreach nurse had already been put in place before the patient's death.
Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sunderland
Concerns raised1
Inaccurate recording or communication of diabetes type
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South and West Cambridgeshire
Concerns raised1
Failure to identify and manage patients' diabetic control
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North London
Concerns raised1
Unavailability of a specialist diabetic nurse at the hospital over weekends
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Appoint at least one whole-time-equivalent inpatient diabetes specialist nurse to provide hospital-wide cover across the calendar week.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 January 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local healthcare organisations are responsible for assessing needs and commissioning and delivering safe diabetes services, including appropriate nursing staff.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of controls specifically dedicated to diabetes care and management, including access to specialist diabetic support, monitoring of glucose or ketones, recognition and escalation of deterioration, diabetic status communication, insulin access and other clinically necessary diabetes-management arrangements.
