Recurring concern

Unreliable diabetes care and management

First to latest report 7 Jan 2014 — 12 Jun 2025

Reports that mention this concern: 14
Times this concern has been raised: 23
Stated actions linked to this concern: 27

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Reports and published responses 14 reports

See individual reports that have raised this concern, and the actions taken in response

23 Mar2015
Manchester South
Concerns raised6
1. Failure of nurses to recognise and escalate deteriorating diabetic care
2. Failure to provide specialist diabetes outreach cover during absence
3. Under-resourcing of diabetes care
1. Unavailability of specialist diabetes outreach nurse advice
2. Deficient nurse training on Type 1 Diabetes
3. 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.
Linked response

Stockport NHS Foundation Trust
Stated actions 12
1. Stockport NHS Foundation Trust
  Commission and complete a diabetes-care Task and Finish Group review, producing an approved action plan.
2. Stockport NHS Foundation Trust
  Amend the Trust Training Needs Analysis to require diabetes training for nurses and doctors.
3. Stockport NHS Foundation Trust
  Design bespoke diabetes training for senior nurses covering night and out-of-hours care, and begin its delivery.
1. Stockport NHS Foundation Trust
  Improve the Diabetes Microsite and increase availability of Diabetes Specialist Nurses to support diabetes management.
2. Stockport NHS Foundation Trust
  Implement an electronic inpatient referral form for requesting diabetes review and support across wards.
3. Stockport NHS Foundation Trust
  Put a sickness-cover and backfill plan in place for the specialist outreach nurse post.
4. Stockport NHS Foundation Trust
  Appoint an additional Diabetes Specialist Nurse and a Diabetes Practice Educator to support the whole Trust.
5. Stockport NHS Foundation Trust
  Provide additional consultant diabetes cover through an agency locum and a Consultant of the Week model.
6. Stockport NHS Foundation Trust
  Purchase and incorporate an NHS England-recommended diabetes e-learning module into the Training Needs Analysis.
7. Stockport NHS Foundation Trust
  Deliver bespoke diabetes-care training to nursing staff on wards M4 and A11.
8. Stockport NHS Foundation Trust
  Add diabetes and insulin management to mandatory three-yearly Essentials training for all staff.
9. Stockport NHS Foundation Trust
  Identify ward link nurses and provide specialist training so they can deliver local diabetes training.
Respondent positions 1
1. Stockport NHS Foundation Trust
  A sickness-cover plan for the specialist outreach nurse had already been put in place before the patient's death.
  Disputes the concern
AI-generated summary

Pamela Pattison · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Pamela Pattison was admitted to hospital after falling at home and fracturing her hip. Her insulin was intentionally omitted following a mistaken assessment, and concerns were raised about sub-optimal diabetic care, inadequate staff training and escalation, insufficient specialist diabetes support, equipment and resourcing problems, and delay in transferring her to an appropriate ward. The medical cause of death was recorded as aspiration pneumonia following nausea and vomiting consequent upon unstable diabetic control, with brittle diabetes and a fractured neck of femur also recorded.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of nurses to recognise and escalate deteriorating diabetic care
Wider context from the report
“1. From the evidence it was apparent that nurse training on wards M4 and A11 was deficient and their understanding of the importance and danger of Type 1 Diabetes seemed to be limited at best. The nurses were unable to say why they had not escalated her care on a number of occasions. ”
Source location
Pamela Pattison · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide specialist diabetes outreach cover during absence
Wider context from the report
“5. The specialist outreach Nurse Practitioner for diabetes was booked off sick for one month, and no 'cover' was in place to cover his absence. ”
Source location
Pamela Pattison · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Under-resourcing of diabetes care
Wider context from the report
“8. It was conceded by the ‘Head of Risk’ for the Trust, that there was a general under resourcing within the Trust for the care of patients with Diabetes. ”
Source location
Pamela Pattison · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of specialist diabetes outreach nurse advice
Wider context from the report
“3. It was evident that the nursing staff on, for example, the surgical wards, did not have any specialist outreach nurse advice on such things as diabetes. ”
Source location
Pamela Pattison · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Deficient nurse training on Type 1 Diabetes
Wider context from the report
“1. From the evidence it was apparent that nurse training on wards M4 and A11 was deficient and their understanding of the importance and danger of Type 1 Diabetes seemed to be limited at best. The nurses were unable to say why they had not escalated her care on a number of occasions. ”
Source location
Pamela Pattison · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of additional diabetes consultant cover
Wider context from the report
“4. There was an obvious need for additional consultant cover for Diabetes. I was told that funding has been put in place to cover this, but as yet no one has been appointed to fulfil this vital role. ”
Source location
Pamela Pattison · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Commission and complete a diabetes-care Task and Finish Group review, producing an approved action plan.

Verbatim wording from the response
“One of our most important actions was the internal commissioning of a “Task and Finish Group” whose remit was “to review the current situation regarding diabetes care to ensure safe and ████████ for all patients with diabetes in hospital”. This was chaired by ████████ Head of Risk and Customer Services, and included senior medical staff, experienced diabetes specialists (both nursing and medical) and senior nurses from across the Trust. I understand the action plan from this group was also shared with you during the inquest.”

Source location
2015-0108-Stockport-NHS-Trust
Page 1 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend the Trust Training Needs Analysis to require diabetes training for nurses and doctors.

Verbatim wording from the response
“a. The Trust Training Needs Analysis (TNA) has been amended to include diabetes training as an essential requirement for all nurses and doctors (see below).”

Source location
2015-0108-Stockport-NHS-Trust
Page 1 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Design bespoke diabetes training for senior nurses covering night and out-of-hours care, and begin its delivery.

Verbatim wording from the response
“Diabetes management advice: Bespoke training session; Hospital and night nurses and those undertaking professional cover; N/A; N/A; N/A”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Improve the Diabetes Microsite and increase availability of Diabetes Specialist Nurses to support diabetes management.

Verbatim wording from the response
“Ensuring that all doctors are aware of the appropriate management of diabetes has been addressed both by training (see above) and by an improved ‘Diabetes Microsite’ and improved availability of Diabetes Specialist Nurses.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement an electronic inpatient referral form for requesting diabetes review and support across wards.

Verbatim wording from the response
“The Trust has also implemented an electronic inpatient referral form for patients needing review, which provides a more robust method for all ward areas to request help or support in managing patients with diabetes.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Put a sickness-cover and backfill plan in place for the specialist outreach nurse post.

Verbatim wording from the response
“This planned sickness had been identified and the manager recognised the need for additional cover and backfill for this post. A plan had been put in place to commence on the 27th January 2014, which is sadly the day Mrs Pattison died.”

Source location
2015-0108-Stockport-NHS-Trust
Page 3 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Appoint an additional Diabetes Specialist Nurse and a Diabetes Practice Educator to support the whole Trust.

Verbatim wording from the response
“Since this incident there has been a merger of community and hospital teams and the appointment of a further Diabetes Specialist Nurse and a Diabetes Practice Educator, who support the whole Trust.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide additional consultant diabetes cover through an agency locum and a Consultant of the Week model.

Verbatim wording from the response
“An agreement was reached to expand the consultant cover within Diabetes & Endocrinology in July 2014. This subsequently went out to advert but unfortunately we have failed to recruit on”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Purchase and incorporate an NHS England-recommended diabetes e-learning module into the Training Needs Analysis.

Verbatim wording from the response
“b. An E-Learning module has been purchased by the Trust (one recommended by NHS England) completion of which is included in the TNA.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver bespoke diabetes-care training to nursing staff on wards M4 and A11.

Verbatim wording from the response
“c. Bespoke training has been delivered to nursing staff on both M4 and A11 in the care of diabetic patients.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add diabetes and insulin management to mandatory three-yearly Essentials training for all staff.

Verbatim wording from the response
“d. ‘Essentials’ training (that which is mandatory for all staff every three years) now includes a session on diabetes and insulin management.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Identify ward link nurses and provide specialist training so they can deliver local diabetes training.

Verbatim wording from the response
“Nurses/Midwives/Allied Health Professionals, Assistant Practitioners, Clinical Community Professionals (See key below): Covered on Essentials for all. Registered Nurses and Midwives and all APs also to complete module ‘Safe use of insulin’ 3 yearly. Tool box training by link nurses – annually”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A sickness-cover plan for the specialist outreach nurse had already been put in place before the patient's death.

Verbatim wording from the response
“This planned sickness had been identified and the manager recognised the need for additional cover and backfill for this post. A plan had been put in place to commence on the 27th January 2014, which is sadly the day Mrs Pattison died.”

Source location
2015-0108-Stockport-NHS-Trust
Page 3 · response
Published 23 March 2015
Open published response
24 Sep2014
Sunderland
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Leonard Henry Hudson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Leonard Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inaccurate recording or communication of diabetes type
Wider context from the report
“During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted. Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor. Mr Hudson ought to have been referred to the foot protection team in a more timely manner. The nursing documentation was not as comprehensive as it ought to have been. The classification of Mr Hudson’s heel injuries was “variable”. From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: - 1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this; 2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist; 3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis; 4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy; 5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; 6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding. However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention. I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths. ”
Source location
Leonard Henry Hudson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Sep2014
South and West Cambridgeshire
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Anne Elizabeth Sandever · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anne Elizabeth Sandever, a diabetic woman with acute on chronic renal failure, was admitted to hospital on 3 February 2014, deteriorated after transfer to Walnut ward, and died on 6 February 2014. The concerns included gaps in nursing and medical observation, poor communication and handover about her diabetes, lack of intravenous fluids despite renal failure, and insufficient investigation of the incident.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify and manage patients' diabetic control
Wider context from the report
“(2) Communication and handover was poor, no one on the ward knew Mrs Sandever was diabetic or took appropriate care of her diabetic control. ”
Source location
Anne Elizabeth Sandever · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Jan2014
North London
Concerns raised1
1. Unavailability of a specialist diabetic nurse at the hospital over weekends
Linked responses

Department of Health and Social Care
Royal Free London NHS Foundation Trust
Stated actions 1
1. Royal Free London NHS Foundation Trust
  Appoint at least one whole-time-equivalent inpatient diabetes specialist nurse to provide hospital-wide cover across the calendar week.
Respondent positions 1
1. Department of Health and Social Care
  Local healthcare organisations are responsible for assessing needs and commissioning and delivering safe diabetes services, including appropriate nursing staff.
  Redirects responsibility
AI-generated summary

Grace Mary Bates · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Grace Mary Bates died in hospital on 21 April 2013 from complications associated with poorly managed diabetic episodes. The report raised concern that no specialist diabetic nurse was available at the hospital over the weekend, during which her blood sugar management was poor.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of a specialist diabetic nurse at the hospital over weekends
Wider context from the report
“(1) That should be a specialist diabetic nurse available over the weekend at the hospital. ”
Source location
Grace Mary Bates · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Appoint at least one whole-time-equivalent inpatient diabetes specialist nurse to provide hospital-wide cover across the calendar week.

Verbatim wording from the response
“Our Head of Diabetes & Endocrinology; Business Manager for Diabetes and our Lead Diabetes Nurse submitted a business case for the approval for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week.”

Source location
2014-0007-Response
Page 1 · response
Published 7 January 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Local healthcare organisations are responsible for assessing needs and commissioning and delivering safe diabetes services, including appropriate nursing staff.

Verbatim wording from the response
“Local organisations are best placed to assess the needs of their populations, and to commission and deliver high-quality, safe and comprehensive diabetes services; including appropriate nursing staff and I expect local healthcare organisations to do their utmost to deliver care against NICE standards as part of a general duty to ensure continuous improvement in quality.”

Source location
2014-0007-Response-2
Page 2 · response
Published 7 January 2014
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

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

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Inaccurate recording or communication of diabetes type

Concerns raised1

Failure to identify and manage patients' diabetic control

Concerns raised1

Unavailability of a specialist diabetic nurse at the hospital over weekends

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Stated actions 12

Respondent positions 1

Stated actions 1

Respondent positions 1