Gillian Astbury. I am not sure if the name rings a bell, but it should. Not just in the world of endocrinology and diabetes, but to anyone involved in healthcare who believes in the basic mantra of ‘Do no harm’.
Gillian was the woman who died in 2007 during the low point of the Mid Staffs scandal. An inquest into her death ruled that low staffing levels and other systemic failures at Stafford Hospital were contributing factors, and that a failure to administer insulin to the 66-year-old amounted to a gross failure to provide basic care. The Mid Staffordshire NHS Foundation Trust was subsequently prosecuted by the Health & Safety Executive. The Trust was fined £200,000 and ordered to pay more than £27,000 in costs over what the judge described as ‘the wholly avoidable and tragic death of a vulnerable patient’.
So, roughly 11 years later, how have things changed?
‘With up to 20% of in-patients having diabetes, should training for all staff involved in handling insulin be compulsory? Or is it less important than, say, fire safety?’
THE CURRENT SITUATION
National audits suggest 1 in 25 patients with type 1 diabetes go into diabetic ketoacidosis in a hospital (a harm rate of 4%) while insulin errors continue to be a consistent feature, albeit dropping over the years. With the population incidence of diabetes increasing, the incidence of those with diabetes in a hospital – at any given time – continues to increase, and so does the number of people on insulin.
However, things have also changed, to an extent for the better. Ten years ago, in-patient diabetes teams were unheard of, but now they form a core part of the diabetes team in most hospitals. However, about 28% of hospitals still do not have a dedicated in-patient diabetes nurse specialist.
However, there is no question that the importance of this has continued to rise in the eyes of national bodies, especially with regard to the safety aspect. 2017/18 saw a fresh injection of money into diabetes care. One of the main areas of focus was improving in-patient safety, with specific emphasis on nursing staff . Approximately £5 million has been invested into recruiting nearly 100 whole-time equivalent nurses across the country, which can only be viewed positively when looking ahead. The national diabetes in-patient audit, performed annually, provides an opportunity to look at improvements (or their absence) while also focusing on areas that need tackling, such as e-prescribing or training.
In addition, a national programme called GIRFT (Getting It Right First Time) has been designed to look at variation in diabetes care across all hospitals in England, with insulin safety being a key focus of this exercise.
LOOKING FORWARD
The question is ‘where next?’. The investment has come, as has the process of benchmarking. Is the next step for some aspects to be mandatory?
With up to 20% of in-patients having diabetes, should training for all staff involved in handling insulin be compulsory? Or is it less important than, say, fire safety? Should all hospitals have a specific panel reviewing diabetes and insulin errors? These are musings which may appear too specialist-centric, but the volume of patients, the rapid turnover of staff, and new insulin of different concentrations perhaps make a case to consider this.
Or is it sometimes about the basics too? Why would a healthcare professional who rarely deals with insulin know more about it than the person who lives with it day in and day out? Why shouldn’t there be self-management protocols for those who can? After all, safety is paramount, and we have at our fingertips the ability to ask someone who is the actual expert: the person living with diabetes.
In summary, there is indeed greater recognition at all levels about the importance of insulin safety, and there are some great examples in places such as Derby, Southampton and Leicester of initiatives which have been helpful in improving care. It’s now a question of how we adapt these good practices, use the money wisely, and tackle issues of general education amongst fellow healthcare professionals.
Beyond all, much of the answer will probably also sit with those we try to look after. It feels as though things are moving in the right direction, with patient charities such as Diabetes UK also focusing on this as a matter of importance. Hopefully with greater awareness, we will, as a system, reach a place where insulin errors are a rarity and a distant memory, in place of an environment where people living with diabetes fear their time in hospital.
Partha Kar, Consultant (Diabetes & Endocrinology), Portsmouth Hospitals NHS Trust Co-lead Diabetes, GIRFT
