Recommendation 2: Insulin
From Thirlwall Inquiry Final Report, published 15 September 2026.
Recommendation
i. Digital devices should be used to restrict access of insulin to authorised people
and record access to insulin storage units. I acknowledge that steps are being taken to
achieve this. By 31 March 2027, all neonatal units must meet the expected requirements
for access control and storage of insulin set out in the NHS England Getting It Right First
Time guide, GIRFT Neonatology: Guide to safe insulin use.
ii. Until access to insulin requires the provision of biometric data, each Trust should install
CCTV cameras focused on storage fridges, cupboards or units. The cameras should store
recordings for at least 28 days.
iii. The GIRFT Laboratory Handling of Insulin Requests in the Investigation of Hypoglycaemia
guidance for the testing and reporting of insulin and C-peptide results, issued in October
2025, must be made mandatory and of national application.
In brief (written by this site)
In September 2026, the Department of Health and Social Care accepted the recommendation, with the Secretary of State, Yvette Cooper, stating that the government agreed to introduce stronger controls on insulin storage while beginning work on safe storage guidance (Yvette Cooper response, Sep 2026; Department of Health and Social Care, Sep 2026). Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer, instructed trusts that same month to urgently install CCTV monitoring insulin storage by 30 November 2026 until biometric access is in place (Duncan Burton; Sarah-Jane Marsh, Sep 2026). Under their directive, all neonatal units must meet required access control and storage standards by 31 March 2027 (Duncan Burton; Sarah-Jane Marsh, Sep 2026).
Sources
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
It recommends much stronger controls on insulin storage. The NHS has begun that process with new guidance in January of this year, but we agree with the recommendation to go further.
Delivery
Department of Health and Social Care says in progress (15 September 2026)
new guidance on the safe use and storage of insulin and strengthened guidance for medical examiners reviewing neonatal deaths
From: Government to act on Thirlwall patient safety recommendations
Site note: Department of Health and Social Care press release of 15 September 2026. The passage is one item in a list of measures the government says it has begun "while it considers the inquiry's recommendations in full"; the release does not number the recommendations. The release gives this item once, for insulin (recommendation 2) and medical examiners (recommendation 11) together, and the same words are recorded on each.
What other bodies have found
In their own words. These do not change the delivery statement above.
NHS England (22 September 2026)
Insulin: By 31 March 2027, all neonatal units must meet requirements for access control and storage of insulin as set out in the GIRFT neonatology guide to safe insulin use. Until access to insulin requires the provision of biometric data, each trust should urgently install CCTV cameras in neonatal units focused on storage fridges, cupboards or units by 30 November 2026 at the latest. The cameras should store recordings for at least 28 days.
From: Thirlwall Inquiry report and recommendations (letter PRN02660)
Site note: NHS England's letter to NHS trusts and integrated care boards (PRN02660), signed by Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer. The letter bears no date; NHS England published it on 22 September 2026, and it calls the leadership event of 22 September "tomorrow". The passage is under the letter's heading "Actions needed now".
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - NHS England
Finding