Cornwall Community Matron Recognised for Diabetes Care Work

A community matron from St Austell has been recognised for transforming diabetes care in Cornwall, helping housebound patients reduce or even stop their insulin use entirely.

Leading the Way in Community Diabetes Care

Catherine Ledbetter, who has worked as a community matron since 2013, has led a new approach to diabetes management for frail and elderly patients. Her work has already prevented unnecessary hospital admissions and helped people like 85-year-old Jack, who was living with multiple long-term conditions, gain back control of their health.

“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,” said Catherine.

“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.”

Empowering Teams to Spot Problems Early

After completing an advanced clinical practitioner apprenticeship, Catherine took a special interest in diabetes. She studied the diabetes module and passed on her knowledge to nursing teams, supporting them to create personalised patient management plans.

“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,” she said.

One of the biggest changes has been the use of continuous blood glucose monitoring. The device, which attaches to a patient’s arm, allows nurses to monitor glucose levels around the clock.

“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,” said Catherine.

This technology has helped the team create personalised plans and reduce the risk of falls or hospital admissions due to tight insulin control. Some patients no longer need insulin or diabetic care.

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

Jack’s Story: From Crisis to Confidence

Jack, 85, lives alone and is a type 2 diabetic. On top of managing insulin, he also lives with heart failure, kidney disease and a skin disorder. He was regularly experiencing both low and high blood sugar episodes, resulting in falls, fractures and emergency hospital admissions.

After being referred to the community nursing team, Jack was fitted with a continuous glucose monitor and given a safer, low-dose insulin. His steroid use was reviewed, and social services were brought in to help with a care package.

The support went beyond just medicine. Social prescribing gave Jack a new lifeline and helped improve his mental health. He was taught how to self-administer insulin safely, which meant nurses were no longer needed for daily visits.

Jack now has regular reviews with the community matron and is being considered for further reductions in his insulin and steroids as his condition improves.

Recognition for a New Approach

Earlier this month, Catherine was a finalist in the Rising Star Award category at the Diabetes Nursing Awards, held on Friday 6th June 2025. She was recognised for her work in reducing diabetes complications among elderly people in the community.

“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,” said Catherine.

“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.”

Catherine’s team also hosts monthly diabetic meetings with local partners to discuss complex cases and share expertise.

“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,” she said.

📷Left to right: Jayne Oxenham, Dr Sarah Jarvis, Catherine Ledbetter at the 2025 Diabetes Nursing Awards