Recurring concern
Unreliable diabetes care and management
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Request correctionFirst reported 7 Jan 2014•Latest report 12 Jun 2025
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
- Individual concerns
- 23
- Date range
- 2014–2025
- Stated actions
- 27
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Inconsistent definition of a month for diabetic medication supplies
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 concernsEach 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.3
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Position
Specific prescription-duration guidance was outside the Repeat Prescribing Toolkit’s agreed scope, which was not intended as a clinical guideline.
Stated by Royal Pharmaceutical Society
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Position
Medication-ordering risks are not usually linked to 28-day versus 30-day duration.
Stated by Royal Pharmaceutical Society -
Position
Calendar-month dispensing is impractical because manufacturer pack sizes, licensing requirements and risks of splitting packs constrain supply.
Stated by Royal Pharmaceutical Society
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Concerns raised1
Lack of integrated healthcare system for diabetes and eating disorders
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 concernsEach 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.4
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Action
Work with regional partners to learn from national pilots and trial integrated T1DE pathways locally.
Stated by NHS Hertfordshire and West Essex Integrated Care Board -
Action
Lead a multi-partner implementation group to improve eating-disorder services and physical-health checks.
Stated by NHS Hertfordshire and West Essex Integrated Care Board -
Action
Reinforce ICB case-discussion support and establish a clearer provider escalation process, with access details due by November 2024.
Stated by NHS Hertfordshire and West Essex Integrated Care Board
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Action
Develop an integrated diabetic-care model covering complex cases, multidisciplinary case management and mental-health support.
Stated by NHS Hertfordshire and West Essex Integrated Care Board
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Concerns raised3
Inconsistent blood-sugar monitoring instructions across documents
Failure to check blood sugar levels twice weekly
Lack of recorded diabetes-specific dietary instructions
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Maintain person-centred diabetes care plans covering hypo- and hyperglycaemia responses and residents’ dietary requirements.
Stated by Runwood Homes PLC -
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 PLC -
Action
Review diabetes menus with catering and nutrition staff at monthly nutritional meetings, minute the discussions and distribute the information to care and kitchen teams.
Stated by Runwood Homes PLC
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Concerns raised1
Lack of standby rapid-acting insulin prescriptions for otherwise stable diabetic patients
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 concernsEach 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
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Action
Embed Home First into the revised pathway to support administration of rapid-acting insulin within two hours of referral when clinically necessary.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board -
Action
Revise insulin authorisation forms, require their use, and include frailty-based dosing guidance and recorded authorisation for ad hoc rapid-acting insulin.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board
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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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Lack of comprehensive diabetes monitoring and management risk review and care planning before discharge
Failure to consider diabetes-related causes of reported side effects and seek appropriate clinical advice
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 concernsEach 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
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Action
Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Address coordination of diabetes management at discharge through the diabetes steering group.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Provide recurring eLearning on physical-health and diabetes management to relevant clinical staff, with knowledge testing.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to provide more frequent diabetes monitoring for individuals at higher risk
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to carry out diagnostic testing and monitoring for diabetes
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Position
Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.
Stated by Department of Health and Social Care
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Concerns raised2
Failure to seek Dementia Outreach Team assistance for deteriorating blood glucose and insulin compliance
Failure to make staff available for pre-arranged Diabetes Nurse appointments
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 concernsEach 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
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Action
Establish regular Dementia Outreach Team referrals, communication and management monitoring for residents requiring support.
Stated by Adbolton Hall Limited -
Action
Ensure nursing and management staff attend all pre-arranged multidisciplinary team appointments.
Stated by Adbolton Hall Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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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 Limited
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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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026