Diabetes in Schools nut health & safety briefing

	Diabetes in Schools NUT HEALTH & SAFETY BRIEFING

This briefing is intended to give information and guidance to teachers which will support and encourage the uninterruped education in schools of children with diabetes.

Symptoms of Diabetes

Diabetes occurs when the body is unable to process glucose properly, either because of a lack of insulin (Type 1 diabetes) or because insufficient insulin is produced, or the insulin available doesn’t work properly (Type 2 diabetes). This leads to a raised level of glucose in the blood, which is unable to be converted - with the help of insulin – into energy.

The main symptoms include increased thirst, extreme fatigue, loss of weight, frequent trips to the toilet, blurred vision, itchiness in the genital area or repeated bouts of thrush.
Diabetes affects around 130 million people worldwide, and the World Health Organisation estimates that this number will more than double by 2025. About one in 550 school-age children have diabetes, with the majority suffering from Type 1, although the number of children with Type 2 diabetes is on the increase – recognised as being linked to obesity.

Treatment for Diabetes

Most children with diabetes need to have injections of insulin every day, check their blood glucose level and eat at regular intervals according to their personal dietary plan, which will usually have been drawn up by a dietician at the hospital. The child’s parents or carers should be able to provide details of this to the relevant staff. Type 2 diabetes is normally controlled by dietary changes and exercise, although some people with Type 2 diabetes require tablets or insulin injections as well.

Symptoms and treatment vary from one person to another, so it is vitally important that an individual health care plan is drawn up by the school for each child with diabetes, as with all chronic illnesses. This plan, which need not be a lengthy or complex document, will summarise all the information relevant to the child’s condition, and should be developed and updated as and when necessary with the full support and involvement of the child, his or her parents/carers, and the diabetes care team. One particularly important member of this team is the diabetes specialist nurse (DSN) who will act as a central point of contact and be able to provide expert advice for the school. Parents or carers of the child should be able to supply further details regarding the diabetes care team and the specialist diabetes nurse, such as who they are and how they can be contacted should the need arise.

Supporting Students with Diabetes

> Drawing Up School Policies and Individual Plans
General information about supporting pupils with diabetes should be included in the school medicines policy, and should reflect DfES and NUT guidance on the subject. This can be achieved simply by including this guidance, and/or that contained in the DfES publication ‘Managing Medicines in Schools and Early Years Settings’. Furthermore, individual health care plans should be drawn up for each child with diabetes in the school. The main purpose of the individual health care plan is to identify the nature of support needed at school. Each student with diabetes will have different needs and these need to be clearly documented in the individual care plan, together with the child’s requirements for supervision, medication and diet. Those who may be involved in devising the plan might include the headteacher, the parent or guardian, the child, the class teacher, support staff members, the diabetes specialist nurse and the school health service or the GP.
Each plan should judge the pupil’s needs individually since each student with diabetes will have a different level of control. The plan should identify the management of the condition, individual symptoms and triggers, arrangements for daily care (including type of medication, blood glucose monitoring and access arrangements), arrangements for medical emergencies (including support from school staff), considerations relating to supervision, diet and exercise. Necessary contact details should include family details and paediatric diabetes clinic as well as the child’s GP. Care plans will need to be reviewed on a regular basis to ensure that that they are still relevant to the needs of the child. The diabetes care team should be able to assist in determining the level of frequency with which the care plan might require revision. The DfES guidance ‘Managing Medicines in Schools and Early Years Settings’ includes model forms for developing individual health care plans, which can be downloaded from:

https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFES-1448-2005.
Remember that there is no legal or contractual duty on teaching staff to administer diabetes medication. Although many school staff are willing to assist students by agreeing to administer medication or supervising the student taking them, this is nevertheless voluntary. Where staff require information or training in this regard, it should always be made available.
> Insulin Injections
Most children of junior school age receive insulin injections twice a day, at breakfast and teatime. Consequently they would not usually require injections during the school day unless they were taking part in school activities involving extended hours such as an educational visit. However, older children who are able to inject themselves may choose to take their insulin 3 or 4 times a day, as this gives them greater control and flexibility in managing their condition. The child would have been trained by the paediatric diabetes team to calculate the amount of insulin to administer each time, depending on the amount of carbohydrate they have consumed. They may well need to test their blood sugar before meals as part of this routine. Where children are following this type of regime, the insulin and injecting equipment would need to be brought in to school, and the pupil concerned should be provided with a suitably private and quiet area where their needs can be met. Adult supervision may be necessary.

All such arrangements should be clearly detailed in the child’s individual health care plan. Where school staff have agreed to administer insulin injections in the case of younger children, they should be fully trained by an appropriate health professional. The school staff will need to be aware of safe disposal of needles and syringes and the local policy for collection.

> Blood Glucose Monitoring
It is important that blood glucose levels are well-managed in the treatment of diabetes. Depending on how frequently their insulin requires adjustment, children with diabetes may need to check their blood glucose levels using a small monitoring device. This is most likely to be necessary at lunchtime and before periods of increased physical exertion such as a P.E. lesson. As before, older children will often be able to manage this for themselves, given time and a suitable place for carrying out the checks. Younger pupils, however, may require the assistance of an adult in administering the test and comprehending its results. No teacher can be compelled to help supervise or administer blood glucose tests or insulin injections. Where a member of staff has agreed to act in this capacity, they should receive full training from an appropriate health professional. School staff should be aware that a child with diabetes may need to be allowed to eat at regular times throughout the day, including, if necessary, during lesson times or before exercise. Care should be taken to ensure that the times at which food is consumed are known and adhered to. Where a school has a staggered lunchtime, the child should attend the same sitting each day. In a canteen setting, it may be necessary to ensure the child can go to the front of the queue.

> Hypoglycaemia (Hypo)
A child with diabetes will suffer a hypoglycaemic episode (a ‘hypo’) when blood glucose levels fall too low. This can happen because of too much insulin, too little food, physical exertion, cold weather or the child vomiting. Staff should look out for signs such as hunger, sweating, drowsiness, glazed eyes, irritability, pallor, lack of concentration, shaking or trembling, headache or mood changes, especially involving angry or aggressive behaviour, any of which are indicative of a hypoglycaemic reaction (hypo) in a child with diabetes. As symptoms will differ from one child to another, it is important to discuss individual patterns with parents/carers when drawing up the child’s individual health care plan and to keep a written record of what they will be. It is vital that a hypo is treated quickly. If untreated, the blood glucose level will continue to drop and the child will become unconscious. Staff should therefore be aware of the warning signs listed above, and ensure that prompt action is taken. In some cases, the child will be able to recognise the symptoms of an impending hypo and take appropriate action themselves, for example by having a sugary drink or glucose tablets but it must be noted that often a child does not recognise their symptoms. Teachers in charge of P.E. lessons, in particular, should be aware of the need to ensure that glucose tablets or a sugary drink are available nearby in case the need arises. On no account should the child should be left alone, neither should they be sent off to get food from elsewhere.
If the child is very drowsy, they may require assistance in treating the hypo. If they are unwilling or unable to eat or drink but still able to swallow, a glucose gel – or a suitable substitute such as honey or jam – should be massaged into the inside of their cheek. If the child loses consciousness, they should not be given anything by mouth. They should be placed in the recovery position (lying on their side with the head tilted back) and an ambulance should be called. In some cases the child may have a seizure, but the above procedure should be followed in any case.
On recovery, the child should eat some starchy food – for example a cereal bar or a couple of biscuits - to prevent the levels of blood glucose falling again. Often children feel nauseous and may vomit following a hypo, so be prepared for this to occur.

The child’s individual care plan should indicate who will provide any adult intervention where it becomes necessary. Whether this responsibility falls to a member of non-teaching staff or a teacher who has volunteered to take it on, they should of course have received comprehensive training from an appropriately qualified health practitioner.

In cases of emergency, teachers must, of course, always be prepared to help as they and other school staff in charge of pupils have a general legal duty of care to act as any reasonably prudent parent would. In such emergencies, however, teachers should do no more than is obviously necessary and appropriate to relieve extreme distress or prevent further and otherwise irreparable harm. Qualified medical treatment should be secured in emergencies at the earliest opportunity.

> Physical Activity

There is no reason why a child with diabetes should not be able to take an active part in physical activity. Indeed, one of the most well-known athletes with the condition is five times Olympic gold medallist Steve Redgrave. However, as any form of activity uses up glucose, it is important that a child with diabetes has something to eat prior to the session, and maybe afterwards as well if, for example, the next meal is not imminent. Additionally, as previously mentioned, suitable sugary food should on hand during the activity in case of need. Again, such arrangements should be clearly detailed in the child’s individual health care plan which all staff should be aware of.

A child who is undertaking a physical activity outside school grounds, such as a cross country run, or a sports event at another location, must wear some form of appropriate ID so that if they become unwell and need medical assistance or first aid, other agencies can provide appropriate assistance.

> Illness

Blood glucose levels can rise when a child with diabetes is unwell – even if they simply have a cold. Symptoms may include thirst and frequent visits to the toilet. If teachers notice such signs, they should ensure that this is reported to the parents/carers in order that insulin doses can be appropriately adjusted. In cases of vomiting the parents should be contacted immediately, as children become acutely ill more quickly than adults and it could easily become a diabetic emergency. The child should be taken to Accident and Emergency if the vomiting persists.

> School Trips
Day trips are unlikely to involve different considerations from those applying to a normal school day. The child should take their insulin and their insulin injection kit as well as any blood sugar testing equipment they would normally need. It is safer if an adult agrees to be responsible for these pieces of equipment in case of loss or damage.
They will also need to take their normal hypo treatment and should ensure that they have sufficient supplies of starchy foods they might need, for example, after an insulin injection.
Where any overnight stays are involved, even if the school staff are confident that the child is competent to administer their own injections, there should be a member of staff who is willing to take responsibility for assisting with injections and blood glucose testing if the child requests help.
Where a child is not able to look after their injections and tests for themselves, some parents may feel uncomfortable about their participation in such a trip, but this in itself is not a reason to refuse the child the opportunity of participation. It is therefore important that a member of staff is willing and able to take responsibility for assisting with or administering injections and blood glucose testing.
Should any medical equipment be lost or forgotten during the trip, the nearest hospital paediatric or Accident and Emergency department should be contacted for help. An emergency identity card or jewellery ID, containing details of the child’s treatment regime, should also be carried by the child and the accompanying adult.
For further advice on such considerations when planning a school visit, especially for trips abroad, the Diabetes UK publication Travel and diabetes contains very helpful information and advice on managing diabetes away from home. Specific guidance is available on local foods and diabetes care in a number of individual countries, including translations of useful phrases. Details of Diabetes UK are included in Further Guidance below.
It is also vital to check that pre-existing conditions such as diabetes are covered by the travel insurance for the trip, in case of medical emergency. Again, Diabetes UK produces specific guidance on this area, Insurance and diabetes, which can be downloaded from www.diabetes.org.uk, or ordered from their distribution department (see Further Guidance below).

Action Points for NUT Safety Representatives

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  Does your school and/or local authority have an effective and user-friendly policy on how children with diabetes should be accommodated in school? Are its contents broadly in line with the advice in this briefing?
  

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  Are the measures set out in the school policy adhered to in practice? For example, how well is information about pupils with diabetes disseminated to staff, including support, supply and temporary staff? Do all staff know the procedure to be followed in the event of an emergency? Are staff aware that children with diabetes may require a snack in the middle of lessons – or even public examinations – and that on no account should such a need be denied?
  

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  Are comprehensive and regularly updated individual health care plans available for each child with diabetes at the school? Are these plans easily accessible to staff, for example posted in the staff room? NB – within the confines of data protection, it is often helpful - especially in larger schools - to affix a recent photograph of the child to the plan to aid identification. Individual health care plans should all be developed in accordance with NUT/DfES guidelines.
  

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  What are the arrangements for the administration of insulin injections or blood tests? Is there a clean, private environment in which such medical interventions can be provided, by trained, competent staff?
  

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  Is sufficient staffing available to support the number of pupils suffering from diabetes at the school? Have such staff received the necessary training? Where teaching staff have volunteered to help in this regard, have they freely given their consent?
  

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  Is there adequate provision for the secure storage of medicines and equipment required by pupils with diabetes? Is such provision easily accessible at all times, so that in the event of an emergency, precious time is not lost in locating the necessary treatment? N.B. In large or split-site schools, consideration may need to be given to the provision of more than one storage location.
  

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  Is there a need for all staff to be made aware of how pupils with diabetes – or indeed other chronic conditions such as asthma, epilepsy or anaphylaxis – can be fully included and effectively supported in school? If not, could such training be arranged for a forthcoming INSET day or twilight session?
  

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  In general, how aware are members of staff of the identity of children with diabetes?
  

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  Are they familiar with at least the main elements of such pupils’ individual care plans?
  

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  Can staff recognise symptoms which may require intervention, and know what should be done in such circumstances? For example, do they know the identity and wherabouts of staff trained to take appropriate action such as the administration of blood glucose testing and/or insulin injections, or – if applicable – the instigation of any relevant emergency procedures*.
  

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  Has the school made appropriate provision in respect of the other considerations mentioned in this briefing - such as food issues, sporting activities and implications regarding school trips?
  

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  Have steps been taken to prevent children with diabetes experiencing – whether intentionally or otherwise - from discrimination? Is there a need for further training for staff on how pupils with diabetes – or indeed other chronic conditions such as asthma, epilepsy or anaphylaxis – can be fully included and made to feel welcome at school? Have existing school policies been revised where such discrimination might have unwittingly occurred in the past?
  

*It may be preferred to designate a named member of staff to take responsiblity for the child, but all staff need to maintain their awareness as outlined above so that problems do not arise should that person be absent for any reason.

Where difficulties arise in securing such agreements with the school management, you are advised to seek further advice, in the first instance, from your NUT Regional Office.

Legal protection for staff or pupils with diabetes in schools

Pupils or staff who suffer from diabetes may not consider themselves to be disabled, but in many cases they will indeed meet the statutory definition of disability set out in the Equality Act 2010 (previously the Disability Discrimination Act (DDA) 1995), and related legislation. The Equality Act requires employers to make reasonable adjustments to the workplace in order that teachers with disabilities are given specific forms of protection from employer discrimination or less favourable treatment. The Special Educational Needs and Disability Act (SENDA) 2001 afforded similar protections to pupils in educational establishments. As a result of SENDA, it is now unlawful for schools to treat disabled pupils – as well as teachers - 'less favourably' than their non-disabled peers for a reason that relates to the person's disability. If a disabled teacher or pupil is, or is likely to be, at a 'substantial disadvantage', schools are legally obliged to take all reasonable steps to prevent that disadvantage, by implementing the aforementioned ‘reasonable adjustments’.

From December 2006 there has been a duty on all schools - to promote disability equality. This means in effect that schools have to show that they are complying with the principles of disability equality in everything they do - right from the planning stage onwards.

Whilst there is no doubt that the majority of schools work hard to ensure the inclusion and welfare of pupils with diabetes, there are still examples of poor practice.
For instance, where

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  a school refuses to admit a pupil with diabetes because of their condition;
  
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  a head teacher excludes a child with diabetes from a school trip on account of their medical needs;
  
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  a pupil with diabetes fails to receive proper care because of poor or non-existent school policies for the effective management of the condition;
  
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  children with diabetes receive punishments for eating in lessons or examinations, despite feeling hypoglycaemic; and
  
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  a school takes little or no action to prevent pupils from bullying a diabetic pupil, or fails to take reasonable steps to prevent theft or damage of essential medical equipment
  

then the school may well be acting unlawfully, as the pupil with diabetes has received less favourable treatment - compared to other pupils - as a result of their condition.

Employers in schools also have a responsibility under the Health and Safety at Work etc. Act 1974 (HASAWA) – and related legislation - to secure the health, safety and welfare of people at work; and to protect pupils against risks to their health or safety arising out of the activities of people at work.
For example, where a pupil suffers as a result of being denied treatment – and this could include the consumption of a snack to relieve a ‘hypo’ – then the school could well be in breach of the HASAWA as well as the provisions of SENDA referred to above.

Further Guidance

> DfES Guidance “Managing Medicines in Schools and Early Years Settings”
The DfES guidance ‘Managing Medicines in Schools and Early Years Settings’ is accessible at

http://www.education.gov.uk/search/results?q=managing+medicines+in+schools+and+early+years+settings
Please note that this supersedes the previous guidance Supporting Pupils With Medical Needs and the related Circular 14/96. It advocates school-based policies and procedures for supporting pupils with medical needs and includes detailed advice on a range of the most common conditions - asthma, epilepsy, diabetes and anaphylaxis - and detailed guidance on safe storage of medicines and on routine and emergency procedures for medical matters.
> DfES Guidance ‘Implementing the Disability Discrimination Act in Schools and Early Years Settings is available from:
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DfES%200160%202006
This includes detailed advice for schools on making reasonable adjustments, including a CD ROM whch provides visual examples.
> Diabetes UK document “Children with diabetes at school”
The Diabetes UK publication “Children with diabetes at school – What all staff need to know” is available at

https://www.diabetes.org.uk/upload/School%20leaflet%2009.pdf
Much other useful material is available on this website, which can be found by going to the Diabetes UK homepage at www.diabetes.org.uk. They can also be contacted as follows:
Diabetes UK Central Office

Macleod House,

10 Parkway, London NW1 7AA
Telephone: [phone]
Fax: [phone]
Email: [e-mail]

Diabetes UK Careline
This confidential telephone helpline offers information and support on all aspects of diabetes. It is operated by trained staff from Mondays to Fridays, 9am to 5pm.
10 Parkway

London, NW1 7AA

Telephone: [phone]

Email: [e-mail]

Further information: http://www.diabetes.org.uk/How_we_help/Careline/

For Diabetes UK Publications, contact

Diabetes UK Distribution
PO Box 1057

Bedford

MK42 7XQ

Telephone: [phone]

Further information: https://www.diabetes.org.uk/OnlineShop/How-To-Order/
NUT Health and Safety Briefings
The NUT has produced a number of Health and Safety Briefings relevant to supporting children with medical needs in schools, which are listed below. They can be obtained from your NUT Regional Office/Wales Office or by telephoning the NUT Health and Safety Unit on 0207 380 4775/4875. They are also available on the NUT website at www.teachers.org.uk.

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  Administration of Medicines
  
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  Anaphylaxis In Schools
  
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  Asthma in Schools
  
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  Dysentery in Schools
  
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  Epilepsy in Schools
  
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  Hygiene Control
  
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  Infectious Diseases
  
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  Meningitis in Schools
  
• 
  Tuberculosis in Schools
  
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  Sickle Cell and Thalassaemia
  

National Union of Teachers

August 2011

NUT Health & Safety Briefing: Diabetes in Schools