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A matron from Cornwall is leading the way in community diabetes care.

Catherine Ledbetter works in the St Austell area. She has been a community matron since 2013. Her latest project has helped to prevent unnecessary hospital admissions. It has improved diabetes care for patients. In some cases, patients have been able to stop insulin and come away from diabetic care.

"Many of our patients are housebound. Most have long-term health conditions. At least 50% of our caseload are living with diabetes as well as other conditions. We expect this number to rise by 50% by 2050.

"We have a large elderly demographic in Cornwall. We have high levels of unplanned hospital admissions and urgent care use. Often this is in those who are diabetic, frail and elderly.

"Many of these people are isolated and live alone. Often community nurses are their main source of review and health information." Catherine Ledbetter

Catherine took a specialist interest in diabetes care after doing an advanced clinical practitioner apprenticeship.

"People are living longer with long-term health conditions such as diabetes. There is a rise in demand for diabetes care in the community. The specialist diabetes team are to capacity. It is key to look for ways to support the team, as well as other ways to help patients."

To improve her knowledge, Catherine went through the diabetes module. She was able to pass on this knowledge to nursing teams. Catherine helped them to create personalised patient management plans that focus on frailty. By spotting issues early, the nursing teams can reduce hospital admissions and empower patients:

"We must take frailty into consideration when prescribing insulin. You would not manage an 80-year-old with the same strict glycaemic numbers as a 20-year-old.

"We began to use continuous blood glucose monitoring. The device attaches to the patient's arm. It allows us to monitor their glucose levels 24 hours a day, 7 days a week."

This type of monitoring allows the team to create an accurate and personalised treatment plan. Some patients have stopped their insulin all together.

"We saw that some patients were having a hypo at night. We then looked at ways reduce their insulin.

"If we manage insulin too tightly, patients can have falls and end up going into hospital. This creates negative outcomes, such as becoming frail."

Some patients have been discharged from diabetic care, as they no longer need insulin. Many have had their insulin reduced.

"Teams have taken part in hypo awareness and insulin safety weeks. They have forged fantastic links with our specialist diabetic teams and GP lead practice nurses.

"We promote quality care by having monthly diabetic meetings with our partners. We look to discuss our most complex patients. This shared approach has been rewarding. It enables instant expert access. It avoids delays in diabetic care."

Earlier this month, Catherine was recognised at the Diabetes Nursing Awards. This was for her work in reducing diabetes in the elderly and who live the community. She was a finalist in the Rising Star Award category:

"I am delighted to have been nominated and even more thrilled to be a finalist. I see it as an acknowledgement of a successful team approach. This approach spans our local community nurses, diabetic specialists, and the integrated neighbourhood of St Austell Healthcare.

"We will keep building our awareness and knowledge to empower better quality care for those living with frailty and diabetes. Many are housebound with unequal access to traditional care pathways."

The awards were held on Friday 6 June 2025. The full list of winners can be found on the Diabetes Nursing Awards website.

Jack

Jack is 85 and a type 2 diabetic. He treats his diabetes with insulin. Jack lives with heart failure, kidney disease, and a skin disorder. Jack lives alone.

Jack was having multiple falls, fractures, and admissions into the acute hospital with both hypo and hyper glycaemia. Many times, he had called 999 for help.

Once he was discharged from the acute hospital, Jack was under the care of community nurses. Jack was resistant to change. He was overusing his insulin and had poor management knowledge, resulting in no hypo awareness. His conditions made him feel depressed and anxious.

The community nursing team identified that Jack was suitable for continuous glucose monitoring. After fitting Jack with a monitor, they changed his insulin to a safer, low dosage. They looked at his steroid use for his skin disorder and the effects on his diabetes.

The community nursing team looked at other holistic ways to help Jack. They engaged social services. They developed a care package. Social prescribing services have given Jack a lifeline too. He now feels less isolated and his mental health has improved.

Jack was taught how to administer his own insulin at a safe dosage. The nurses are now no longer required. This allows them to support other people in the community.

Finally, Jack has regular reviews with the community matron. They are looking to further reduce his insulin and steroids as his conditions improve.