First reported 25 Jul 2014•Latest report 13 Jan 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to measuring, monitoring, reviewing or following up blood glucose levels, including inaccurate measurement, omitted or untimely testing, inadequate trend review and failure to establish whether testing was completed after refusal, across relevant clinical and care settings.
Not included
Excludes broader diabetes-care failures where blood-glucose measurement or monitoring is not the identified unsafe condition.
Excludes failures limited to prescribing, administering or supplying insulin or other treatment after reliable glucose monitoring has occurred.
Excludes generic equipment, staffing, training, documentation or escalation deficiencies unless they directly impair the blood-glucose measurement or monitoring process.
Excludes glucose-tolerance testing and other diagnostic testing where the concern is pregnancy-status identification, test-request information or interpretation rather than monitoring blood glucose levels.
Reports
13
Distinct published reports
Individual concerns
18
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
19
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
Bank Close House1
Bilbrook Medical Centre1
Blackpool Teaching Hospitals NHS Foundation Trust1
Care Quality Commission1
Four Seasons Health Care Group1
Maidstone and Tunbridge Wells NHS Trust1
Medicines and Healthcare products Regulatory Agency1
National Institute for Health and Care Excellence1
Northern Care Alliance NHS Foundation Trust1
Royal Free London NHS Foundation Trust1
Runwood Homes Limited1
South London and Maudsley NHS Foundation Trust1
Springfield House Nursing Home1
NHS trust5
Ministerial department3
Healthcare site2
Nursing home2
Care-home operator1
Executive non-departmental public body1
Health and social care service regulator1
Independent healthcare provider1
Medicines and medical devices regulator1
Residential care 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.
Derby and Derbyshire
Concerns raised1
Failure of care home staff to perform blood sugar pin prick testing for ill residents with Type 2 Diabetes
This report raised 1 other concern. 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.2
Action
Instruct staff to request immediate blood glucose testing from external professionals when diabetic residents show illness or other concerning health changes.
Stated by Bank Close HouseStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Continue monitoring and reviewing arrangements until the blood glucose testing training pathway and responsibilities are formally confirmed.
Stated by Bank Close HouseStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The home disputes that care staff should undertake blood glucose testing, relying on consistent contrary guidance from external healthcare professionals.
Stated by Bank Close HouseDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Until care staff are trained and assessed as competent, external healthcare professionals will undertake blood glucose testing for diabetic residents.
Stated by Bank Close HouseRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The home cannot implement staff blood glucose testing until external professionals confirm training, competency requirements and clinical governance arrangements.
Stated by Bank Close HouseUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure of blood gas machines to clearly indicate unrecordably low blood glucose levels
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.3
Action
Investigate whether interpretation of glucose and other out-of-range point-of-care analyser results presents a wider safety issue.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Action
Share applicable report details with the manufacturer for review through its ongoing post-market surveillance.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Action
Work with the trust to resolve any identified training issues relating to interpretation of analyser results.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Norfolk
Concerns raised2
Inconsistent blood-sugar monitoring instructions across documents
Failure to check blood sugar levels twice weekly
This report raised 11 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.2
Action
Maintain person-centred diabetes care plans covering hypo- and hyperglycaemia responses and residents’ dietary requirements.
Stated by Runwood Homes PLCStated completedThe respondent said that this action was complete when they made their response on 1 December 2022.
Action
Monitor blood glucose and obtain blood tests every three to six months for residents with diabetes through the GP practice.
Stated by Runwood Homes PLCStated completedThe respondent said that this action was complete when they made their response on 1 December 2022.
Berkshire
Concerns raised1
Failure to identify and clarify blood sugar monitoring issues
This report raised 7 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 West Kent
Concerns raised1
Failure to correctly monitor blood sugar and ketone testing
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.10
Action
Implement the approved blood-glucose monitoring guideline, including traffic-light interpretation, hypoglycaemia management and escalation procedures.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Provide monthly induction training for clinical support workers, registered nurses and junior doctors on diabetic monitoring, equipment, escalation and referrals.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Deliver additional registered-nurse and clinical-support-worker study days using the case and related serious incidents as teaching scenarios.
Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Purchase and deploy blood-ketone testing machines to key locations, with emergency-department nursing training and specialist-nurse support.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Include dedicated blood-glucose-guideline training and case learning in junior-doctor induction programmes.
Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Deliver targeted staff training and share case learning on testing, abnormal-result response and escalation to medical or diabetes teams.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Develop and introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.
Stated by Maidstone and Tunbridge Wells NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Action
Deliver ward-based diabetes-monitoring training through specialist nurses and link nurses.
Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Implement an organisation-wide diabetes-monitoring awareness strategy using the Patient Safety Calendar, guideline launch and bespoke training days.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Disseminate the blood-monitoring guidance through presentations at remaining Trust Clinical Governance days.
Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Nottinghamshire
Concerns raised2
Failure to recognise an incorrect blood glucose reading
Inability to accurately obtain blood glucose levels
This report raised 8 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.1
Action
Purchase new blood-glucose monitoring machines and assess staff competency in using them.
Stated by Adbolton Hall LimitedStated completedThe respondent said that this action was complete when they made their response on 16 June 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The inaccurate blood-glucose reading is considered an isolated incident because the staff member no longer works there and no further incidents occurred.
Stated by Adbolton Hall LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Diabetes care is considered adequately assessed and provided because relevant authorities were satisfied the home’s complex-needs admissions were safe.
Stated by Adbolton Hall LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
Concerns raised1
Inadequate monitoring and review of blood sugar levels and pump-generated data
This report raised 2 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.
Blackpool and the Fylde
Concerns raised1
Lack of clear instructions and staff knowledge for monitoring diabetic patients with sepsis
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.
Inner South London
Concerns raised2
Failure to provide appropriate care plans addressing the risks of refused urine and blood glucose testing
Failure to follow up refused glucose and urine testing for patients on antipsychotics
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Testing patients who refuse blood or urine samples is constrained by the practical difficulty and unpleasantness of restraint.
Stated by South London and Maudsley NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
North London
Concerns raised1
Failure to perform routine blood sugar testing during long-term Clozapine treatment
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
Share the coroner’s report with NHS England.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 13 May 2015.
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Includes failures of controls specifically dedicated to measuring, monitoring, reviewing or following up blood glucose levels, including inaccurate measurement, omitted or untimely testing, inadequate trend review and failure to establish whether testing was completed after refusal, across relevant clinical and care settings.
