WARNING LETTER
Beta Bionics, Inc.
MARCS-CMS 717927 —
January 28, 2026
Product:
Medical Devices
Recipient:
Recipient Name
Sean Saint
Recipient Title
Chief Executive Officer
Beta Bionics, Inc.
11 Hughes
Irvine
,
CA
92618
United States
(b)(6)@betabionics.com
Issuing Office:
Center for Devices and Radiological Health
United States
WARNING LETTER
CMS #717927
January 28, 2026
Dear Mr. Saint:
During an inspection of your firm located in Irvine, CA from June 9, 2025, through June 26, 2025, investigators from the United States Food and Drug Administration (FDA) determined that your firm manufactures the iLet Dosing Decision Software and the iLet ACE Pump, which are part of the iLet Bionic Pancreas System. Under section 201(h) of the Federal Food, Drug, and Cosmetic Act (the Act), 21 U.S.C. § 321(h), these products are devices because they are intended for use in the diagnosis of disease or other conditions or in the cure, mitigation, treatment, or prevention of disease, or to affect the structure or any function of the body.
Quality System Regulation Violations
This inspection revealed that these devices are adulterated within the meaning of section 501(h) of the Act, 21 U.S.C. § 351(h), in that the methods used in, or the facilities or controls used for, their manufacture, packing, storage, or installation are not in conformity with the current good manufacturing practice requirements of the Quality System regulation found at Title 21,
Code of Federal Regulations
(CFR), Part 820.
We received responses from Neal Grant, Director, Quality Systems dated July 18, 2025, August 29, 2025, and October 29, 2025, concerning our investigator’s observations noted on the Form FDA 483 (FDA 483), List of Inspectional Observations, that was issued to your firm. We address this response below, in relation to each of the noted violations. These violations include, but are not limited to, the following:
1. Failure to adequately establish and maintain procedures for corrective and preventive action, as required by 21 CFR 820.100(a). For example:
A. Your firm failed to adequately analyze quality data, such as complaints, to identify existing and potential causes of nonconforming product or other quality problems and utilize appropriate statistical methodology to detect recurring quality problems. For example:
i. Your firm failed to implement corrective and preventive actions (CAPA) for complaints related to device malfunctions that led to serious adverse health outcomes, as required by Section 6.1.3 (Section 1.4 of Revs G and H) of your firm's corrective and preventive action procedure, Corrective and Preventive Actions, SOP05, Rev I, Section 6.1 (Section 6.6 of Rev I) of the firm's complaint handling procedure, Product Complaints, SOP13, Rev H, and Section 9 (Section 6.9 Rev I) of the firm's complaint handling procedure, Product Complaints, SOP13, Rev H.
a. Investigators observed
(b)(4)
complaints reporting Faulty Motors, including one reporting the patient suffered Diabetic Ketoacidosis, confirmed by your firm to be device malfunctions, where you took no corrective actions and provided no justification for inaction, despite identified safety risks.
b. Investigators observed
(b)(4)
complaints reporting hypoglycemic episodes that were attributed to Use Error – Unintended Insulin Delivery associated with the patients’ incorrectly changing the insulin cartridges. 107 complaints were submitted to the FDA as serious injury Medical Device Reports for severe hypoglycemia or intervention required to prevent severe hypoglycemia. Your firm's User-Related Risk Analysis, RA000021, identified that use errors with the iLet Bionic Pancreas System could trigger unintended insulin doses potentially large enough to cause death (classified as the highest risk level, Severity
(b)(4)
). Despite this identified safety risk, your firm closed 56 related complaints without implementing corrective actions to address the identified use errors or documenting justification for why corrective actions were deemed unnecessary.
ii. Your firm conducts complaint trending through your risk management procedure, Risk Management Review, SOP 14.1, Rev B, Release Date 2023-03-13, to determine if escalation to corrective and preventive action (CAPA) is warranted. Your firm’s complaint trending process is inadequate, in that:
a. Inconsistencies were observed between what your firm claims to analyze versus what is documented in your trending analysis. For example:
1. Your firm’s complaint trending provided uses “As Reported Complaint Code: Term” and the part of the system (e.g., iLet device, luer connector, cartridge, etc.), but it does not trend complaints by “Complaint Conclusion” unless there was an associated MDR. Your firm’s Vice President of Quality Assurance stated that they also look at complaint conclusions on everything (with the exception of “not our product”) but that it was just not in the presentation.
2. Multiple codes with identical or nearly identical meanings were found (e.g., "Use Error – User Did Not Announce Meals" vs. "User Error – Did Not Announce Meals"). Similar codes could dilute trending data for specific complaint types like meal announcements.
b. Your firm uses multiple trending rates for complaint analysis that could lead to underestimation of meal announcement complaint rates, potentially affecting safety signals and risk assessment accuracy. For example: Your firm’s complaint trending uses trending rates, such as quantity of complaints per month and as a percentage of the total iLet shipments within a given time period. Your firm’s Vice President of Quality Assurance explained that they also use rates per opportunity. For example, users have approximately ten (10) opportunities to change their cartridge per month, so your firm will trend the percentage by
(b)(4)
. A second example is that users have approximately 90 opportunities to meal announce (three times a day over 30 days), so your firm will trend the same as previous except
(b)(4)
. Your trending rate for meal announcements (90 per month) is not representative of all users’ eating habits and as such might be affecting the rate at which your firm is trending meal announcement related complaints. In addition, your firm’s instructions state that “If you eat a very low carb diet or no carbs at all, you should not announce meals.”
B. Your firm's verification of effectiveness (VOE) for CAPA 0050 is inadequate, in that, it tested
(b)(4)
employees on updated training materials, rather than actual iLet users, which was not representative of user population base (e.g. people 6 years of age or older with diabetes mellitus). Additionally, your CAPA 0050 does not address the allegations of hypoglycemia during the adaptation phase of initial use of the iLet.
Your firm opened CAPA 0050 to investigate hypoglycemia allegations during the iLet Bionic Pancreas System's initial adaptation phase. Your firm determined that the root cause was users' inadequate understanding of diabetes management while using the device, leading to maladaptive behaviors and misuses. Your firm documented the related misuses in RA000021, Rev. E, User-Related Risk Analysis. Your firm initiated preventive actions for CAPA 0050, to include: 1) Holding office hours for health care providers; 2) Improving user training materials; 3) Creating information materials for users transitions from hybrid closed-loop systems and for users new to pump therapy; and 4) Improving guidance materials for health care providers.
Additionally, Section 2.8.3 of your firm's corrective and preventive action procedure, Corrective and Preventive Actions, SOP05, Rev H, Release Date 2024-01-09, and section 1.1 of your firm’s work instruction, CAPA Process, WI000053, Rev C, Release Date 2024-01-09, state that an independent investigator and not the CAPA owner is responsible for executing the verification of effectiveness plan and documenting such activity. However, your firm’s CAPA owner also completed the verification of effectiveness activities for CAPA 0050.
C. Your firm’s procedure, Corrective and Preventive Actions, SOP05, Revs G – I, states that CAPA requests are warranted for systemic issues that affect the quality of products or services, especially if: an incident caused injury or death; there are multiple occurrences of the same event, typically three within a rolling
(b)(4)
period; or a risk assessment identifies the issue as critical. Your firm failed to maintain records to demonstrate that the cause of nonconformities was investigated; the appropriate action(s) needed to correct and prevent recurrence of nonconforming product were identified; actions taken were verified or validated to ensure the actions were effective and did not adversely affect the products; changes in methods and procedures were implemented; and that information related to the nonconforming products was disseminated to those directly responsible for assuring the quality of the products or prevention of such products.
Specifically, investigators observed 15 complaints (dated from July 2023 – December 2023) reporting damaged pump displays, where your firm's product evaluation confirmed the screens were bowed or delaminated. Per your firm’s System Risk Analysis, iLet Bionic Pancreas System, DeLorean (Insulin), RA000005, the risk to patients from being unable to read the display can result in hyper or hypoglycemia and is assigned a Severity of
(b)(4)
(Life-threatening serious injury that requires emergency professional medical intervention). Your firm implemented design changes to address these nonconformities (adding Vent to housing to vent internal volume of iLet to ambient pressure, per QP000171); however, no records were maintained to document any corrective actions or reference to CAPA records.
D. Your firm failed to adequately document its investigation into device failures due to 5-minute delayed glucose readings instead of real-time data. Your associated Health Hazard Analysis, HHA-2024-002, dated 04/12/2024, states that this issue could potentially lead to the basal and/or correction controller not increasing insulin dosing for high or upward trending Continued Glucose Monitoring (CGM) values or the basal controller not reducing or suspending insulin based on downward trending CGM values. Reportedly, this issue was investigated in collaboration with your CGM supplier, resulting in your firm implementing a temporary software change on 04/05/2024 to mitigate patient risks, while your supplier implemented a permanent solution, however, your firm failed to document this investigation.
We reviewed your firm’s responses dated July 18, 2025, August 29, 2025, and October 29, 2025, and conclude that they are not adequate. Your firm's assessment conducted in CAPA 0061 - CAPA VoE Review states, in relation to CAPA-0050, that the Verification of Effectiveness (VoE) was appropriate because it directly measured users' understanding after updated training, addressing the identified root cause, user knowledge gaps. The 100% pass rate on the assessment demonstrates that the revised training effectively improved comprehension related to safe iLet use. However, your firm also indicated in your response that you updated your VoE plan for CAPA-0050 and established a new plan to evaluate CGM-measured percent median time below 54 mg/dL in the user population before and after corrective measures implementation. Your success criteria was established as a
(b)(4)
% or greater reduction in percent median time below 54 mg/dL, which you state would indicate effectiveness of the corrective measures. Supporting evidence of new CAPA-0050 Verification of Effectiveness (VoE) plan was not provided. The root cause determination and verification of effectiveness criteria for CAPA-0050 is deficient in that it fails to distinguish between system design issues versus user training deficiencies and subsequently the preventive actions were solely focused on training improvements without addressing potential device design issues. It is not clear if an evaluation was made of whether the iLet's design of device (e.g. user interface, alert systems, or other potential design issues) could have contributed to maladaptive behaviors.
2. Failure to adequately establish and maintain procedures for validating the device design to include an adequate risk analysis, as required by 21 CFR 820.30(g). For example:
Your firm’s risk management procedure, Risk Management Review, SOP 14.1, Rev B, Release Date: 2023-03-13 states in Sections 1.2 – 1.3 that the Head of QA has overall responsibility for collecting and reporting post market feedback information to management to determine if the product is performing within the risk profile as determined by the products risk management documentation. The following sources provide information that is assessed against the associated risk management documentation: Management Review, Design Testing (non-clinical), Regulatory affairs information pertinent to the bionic pancreas, Nonconforming Material Reports (NCMRs), Manufacturing Data (e.g., yields), Complaints, Health Hazard Assessments, Competitor Information, Published Literature, Customer Feedback including surveys, Clinical Investigations and Follow up. The review of design, production and post market surveillance data and its assessment against the risk profiles per the related risk management documentation shall occur
(b)(4)
, at a minimum.
Your firm's System Risk Analysis, RA000005, for your iLet Bionic Pancreas, failed to include post-market risks identified through your firm’s complaint data, as required by your procedure. Specifically,
A. Your firm has failed to incorporate known post-market safety data into your risk management processes.
i. Investigators observed
(b)(4)
complaints, dated October 2024 – June 2025, reporting various malfunctions of the iLet Bionic Pancreas Model TA000036 caused by failure of the devices’ printed circuit board assembly manufactured by a supplier. Your firm’s risk analysis does not assess, or control identified hardware hazards.
ii. Investigators observed two complaints, received on 02/07/2024, and 01/01/2025, reporting over infusion of insulin resulting in severe hypoglycemia or hypoglycemia requiring medical intervention where the users reported involuntary meal announcements. Your firm’s risk analysis fails to assess hypoglycemia risk from involuntary meal announcements.
B. Your firm’s risk management procedure, Risk Management Review, SOP 14.1, Rev B, Release Date: 2023-03-13 states in Section 4 – Unanticipated Risks that as a result of the risk management assessment per this SOP, any unanticipated events are assessed based upon the severity and occurrence of the associated harm and hazard. This assessment includes a review of prior Design Verification Testing (DVT) and/or Process Validation activities to verify potential, applicable risk mitigations previously established. Rationale for non-escalation shall be documented in the RMRR and approved by the Head of Quality.
Your firm has identified a hazard; however, the risk control implementation and validation are absent in your firm’s risk analysis. Specifically,
Complaint # COM-0000000790 was reviewed reporting a patient with dementia gave themselves multiple successive meal boluses, although they were not eating. The following morning the patient’s blood glucose was 40 mg/dl. The caregiver attempted to wake the patient, but the patient was unresponsive. While your firm’s System Risk Analysis identifies that vulnerable populations (patients with diminished capacity), might be making inappropriate therapy decisions, resulting in hyper or hypo glycemia, your risk analysis fails to: 1) Document any risk control measures to address this specific hazard; 2) Demonstrate calculation of post-mitigation risks; 3) Show how the identified risk is being adequately controlled.
C. Despite approximately 529 complaints reporting insulin cartridges or cartridge connectors leaking while in use, your firm's System Risk Analysis, RA000005, for the iLet Bionic Pancreas does not evaluate the risk to patients from cartridges and cartridge connectors leaking during use.
We reviewed your firm’s responses dated July 18, 2025, August 29, 2025, and October 29, 2025, and conclude that they are not adequate. Your firm’s response states that you plan to update your risk management procedures; however, it does not address whether and how data sources from your firm’s quality system, such as complaints, CAPAs, nonconforming product, etc., will interface with your firm’s risk analysis process to determine if further corrective actions or regulatory decisions are required.
3. Failure to adequately establish and maintain procedures for receiving, reviewing, and evaluating complaints by a formally designated unit, as required by 21 CFR 820.198(a).
A. Your firm failed to adequately investigate complaints involving the possible failure of a device, labeling, or packaging to meet any of its specifications. For example:
i. Investigators review of complaint data from June 2023 – June 2025 found over 500 complaints reporting iLet Bionic Pancreas system insulin cartridges or cartridge connectors leaking. The System Risk Analysis, iLet Bionic Pancreas System, DeLorean (Insulin), RA000005, does not identify the risk to patient from cartridge/connector leaks leading to under delivery of insulin to patients; however, the Risk Analysis identifies the risk of system under-delivery of drug resulting in hyper or hypo glycemia due to administration sets leaking as Critical - Results in permanent impairment of life-threatening injury.
Your firm did not adequately address 31 complaints relating to cartridge or connector leaking. Specifically, your firm closed these complaints without investigation, concluding that no product deficiencies or defects were indicated, and that the complaints did not warrant an investigation. Additionally, by not investigating these product failures, your firm failed to recognize safety risks that could cause adverse events. For example, 18 of the 31 complaints (e.g., COM-0000007869, COM-0000007398, and COM-0000007157) reported that patients experienced hyperglycemic health effects.
ii. Investigators observed that your firm failed to adequately investigate 21 complaints involving bent cannulas or infusion set failures associated with reports of diabetic ketoacidosis (DKA). Your iLet Bionic Pancreas System is distributed to customers with Convatec Inset and Contact Detach infusion sets manufactured for you by your infusion set supplier. Your firm is responsible for intake of complaints for the infusion sets and forwarding them to Convatec. Review of your complaint data shows that approximately 33% of the complaints in your complaint database are related to failure of the infusion sets, with the top failures reported as bent cannula, adhesive issues, and infusion set failures, and with 99.7% of the affected sets not returned by the customers. However, your firm did not request the sets to be returned for further investigation by your infusion set supplier.
B. Your firm failed to implement and maintain adequate complaint files, per your procedures.
Specifically, investigators observed that your firm had not adequately implemented your complaint handling procedure, Product Complaints, SOP13, Rev H, Release Date 2023-01-28, which requires review of all reported product experiences within
(b)(4)
to determine if they constitute a complaint.
(b)(4)
is the electronic quality management system, used by your firm. Your firm’s work instruction, WI000085, provides instructions for completing the product complaint process. Section 6 of work instruction WI000085, Revs A-C, state that if a complaint was created via
(b)(4)
(e.g., Case), various fields such as Event as Reported, Event Date, Aware Date, etc. will be auto filled into
(b)(4)
. It also describes how new complaints can be directly entered into
(b)(4)
.
For example, your firm did not adequately address a user reported hyperglycemic event,
(b)(4)
Case 00015304, involving your iLet device. Specifically, on June 3, 2024, a user reported hyperglycemic event requiring emergency room treatment and insulin administration. On June 5, 2024, the user provided additional details including blood glucose reached 476 mg/dl, stayed high for over 4 hours, and patient developed diabetic ketoacidosis (DKA). On June 5, 2024, your firm closed the case without proper evaluation to determine if it required escalating to a product complaint or if it required reporting. Your firm’s Vice President of Quality Assurance confirmed this was a complaint on June 11, 2025.
The adequacy of your firm’s responses cannot be determined at this time, as corrective actions are ongoing. Your firm has committed to implementing a new complaint handling system by October 29, 2025. Corrective actions, such as a retrospective review of complaints, are ongoing, and your firm did not provide complete evidence of implementation of your new complaint handling system. Without this documentation in hand, FDA cannot make an assessment with respect to adequacy. Please continue to send updates regarding the implementation of your corrective actions.
4. Failure to adequately establish and maintain procedures to control product that does not conform to specified requirements, as required by 21CFR 820.90(a). For example:
Your firm failed to adequately control product that does not conform to specified requirements. Firm's procedure for controlling nonconforming product is SOP09, Nonconformance Reporting.
Nonconformance Report NCR #191 was opened after 61 out of
(b)(4)
iLet Bionic Pancreas printed circuit board assembly (PCBA) Mainboards failed testing due to faulty
(b)(4)
connections. Your firm claimed to have investigated with their supplier, your Vice President of Quality Assurance acknowledged that this investigation was not documented, and no corrective action was taken from the supplier, because this was considered a first-time issue. Your firm later received 19 customer complaints related to iLet Bionic Pancreas Model TA000036 failures caused by defective PCBA Mainboards with improperly installed compone
nts.
We reviewed your firm’s responses dated July 18, 2025, August 29, 2025, and October 29, 2025, and conclude that they are not adequate. Your firm’s CAPA 0064 NCR/SCAR Review table shows instances where your firm has decided no SCAR is to be opened. The justifications for the following instances are inadequate:
Components no longer active (
i.e. Component is no longer active in current iLet (TA000048) configuration
). It is not clear if these non-conformances still being tracked and adequately investigated. Your response does not address if there are devices in the field that still contain this component or if the supplier still provides components that are active. There are repeated instances in table where the same supplier has sent mixed lots of components, manufactured to incorrect part number or sent mislabeled components, but no SCARs were issued.
Component manufactured to incorrect Part Number or Revision (
i.e. the components were found manufactured to the incorrect part number. […] No SCAR will be issued as the parts were manufactured using equivalent materials. […] No additional NCRs were issued for a similar incident.
)
Damage during transportation (
i.e. Damage to external shippers
). It is not clear if these non-conformances still being tracked and adequately investigated.
Typographical errors (
i.e. Expiration Date on CoC was incorrect. […] The incorrect expiration on the CoC was a typographical error. The CoC was updated to the correct expiration date that was stated on the product.
)
Medical Device Reporting (MDR) Violations
Our inspection also revealed that your firm’s iLet Dosing Decision Software and the iLet ACE Pump are misbranded under section 502(t)(2) of the Act, 21 U.S.C. § 352(t)(2), in that your firm failed or refused to furnish material or information respecting the device that is required by or under section 519 of the Act, 21 U.S.C. § 360i. 21 CFR Part 803 - Medical Device Reporting was promulgated under section 519 of the Act, among other provisions. Significant violations include, but are not limited to, the following:
1. Failure to report to the FDA the information required by 21 CFR 803.52 in accordance with the requirements of § 803.12(a), no later than 30 calendar days after the day that your firm received or otherwise became aware of information, from any source, that reasonably suggests that a device that it markets may have caused or contributed to a death or serious injury, as required by 21 CFR 803.50(a)(1). Manufacturers should submit a separate report for each device that it markets that may have caused or contributed to a death or serious injury. For example,
A. The information included for Complaint COM-0000008592 describes an event in which a patient experienced hyperglycemia and chest pains while using your firm’s iLet Dosing Decision Software and was subsequently treated with IV fluids and Insulin. The IV fluids rehydrated the patient and corrected electrolyte imbalances, while IV insulin provided a way to lower the high blood sugar (hyperglycemia). If left untreated, chronic hyperglycemia can lead to diabetes complications, such as cardiovascular disease, nerve damage, eye disease and kidney damage. Based on the information included for the complaint and the medical intervention given to the patient, we determined that your firm’s device may have caused or contributed to a serious injury as defined by 21 CFR 803.3(w)(3). The medical intervention was necessary to preclude permanent impairment of a body function or permanent damage to a body structure. Therefore, this event meets the definition of a MDR reportable event under 21 CFR 803.3(o)(2)(i) because the serious injury was or may have been attributed to the iLet Dosing Decision Software, or the iLet Dosing Decision Software was or may have been a factor in a serious injury. Your firm became aware of the event on August 19, 2024, when you acquired the information in this complaint that reasonably suggested a reportable event had occurred. However, no MDR was
B. The information included for Complaints COM-0000025536, COM-0000026475, COM-0000026763, COM-0000003142 and COM-0000005866 describe adverse events in which patients experienced hypoglycemia with blood sugar levels below 70 mg/dL, while using your firm’s iLet Dosing Decision Software, and were treated with glucose drink or candies to raise their blood glucose level. We determined that treatment for hypoglycemia that includes glucose drinks or candies is a medical intervention necessary to preclude permanent impairment of a body function or permanent damage to a body structure because, if left untreated, hypoglycemia can lead to confusion, shakiness, dizziness, and weakness, but if severe and untreated, it can progress to serious complications like seizures, loss of consciousness (fainting), brain damage, coma, and even death. Repeated episodes can also cause reduced cognitive function, cardiovascular issues, and increased risk for future severe lows. Therefore, based on the information included for the complaints involving your firm’s device and the medical intervention given to the patients, we determined that your firm’s device may have caused or contributed to a serious injury as defined by 21 CFR 803.3(w)(3). Each of these events therefore meet the definition of an MDR reportable event under 21 CFR 803.3(o)(2)(i) because the serious injury was or may have been attributed to the iLet Dosing Decision Software, or the iLet Dosing Decision Software was or may have been a factor in a serious injury. Your firm became aware of the information included for Complaint COM-0000025536, which reasonably suggests a reportable event has occurred, on April 23, 2025, and FDA received the corresponding MDR 3019004087-2025-00443 on July 14, 2025, which exceeds the required 30-calendar day timeframe in 21 CFR 803.50(a). Your firm became aware of the information included for Complaint COM-0000026475, which reasonably suggests a reportable event has occurred, on April 30, 2025, and FDA received the corresponding MDR 3019004087-2025-00461 on July 9, 2025, which exceeds the required 30-calendar day timeframe. Your firm became aware of the information corresponding to Complaint COM-0000026763, which reasonably suggests a reportable event has occurred, on May 3, 2025, and FDA received the corresponding MDR 3019004087-2025-00581 on June 10, 2025, which exceeds the required 30-calendar day timeframe. Your firm became aware of the information corresponding to Complaint COM-0000003142, which reasonably suggests a reportable event has occurred, on April 1, 2024, and FDA has not yet received an MDR. Your firm became aware of the information included for Complaint COM-0000005866 on June 20, 2024, however, FDA has not yet received an MDR.
2. Failure to report to FDA the information required by 21 CFR 803.52 in accordance with the requirements of § 803.12(a), no later than 30 calendar days after the day that your firm received or otherwise became aware of information, from any source, that reasonably suggests that a device that it markets has malfunctioned and this device or a similar device that your firm markets would be likely to cause or contribute to a death or serious injury, if the malfunction were to recur, as required by 21 CFR 803.50(a)(2).
For example, the information included for complaints COM-0000004919, COM-0000008065 and COM-0000008452 reasonably suggests that the firm’s iLet ACE Pump malfunctioned (e.g. component failures: memory chips,) while in use, meaning the device failed to meet its performance specifications or otherwise perform as intended under 21 CFR 803.3(k). Specifically, complaint COM-0000004919 describes an “Alert 60 - Bluetooth Communication” error, complaint COM-0000008065 describes a “Touchscreen unresponsive” error, and complaint COM-0000008452 describes a sleep/wake button unresponsive” error. Although the malfunction alerts reference different alert codes, each malfunction is associated with a defective hoverboard. A device malfunction that is associated with a defective hoverboard has previously resulted in a patient sustaining a serious injury. (Refer to complaint COM-0000003142). This prior incident demonstrates that such a malfunction (i.e., one that is associated with a defective hoverboard) is linked to a serious injury. It is reasonable to conclude that a recurrence of these malfunctions that are associated with a defective hoverboard would therefore be likely to cause or contribute to a serious injury. As such, the malfunctions listed in these complaints represent MDR reportable events for which MDRs must be submitted. Your firm became aware of Complaint COM-0000004919 on 5/25/2024, Complaint COM-0000008065 on 8/8/2024 and Complaint COM-0000008065 on 8/8/2024 however, based on our records, FDA has not yet received an MDR for each of the referenced malfunction events.
The adequacy of your firm’s response dated July 18, 2025, cannot be determined at this time. In the response, your firm noted it initiated corrective actions to address the reporting issue, including a retrospective review of complaints received since June 2023. However, documentation of these corrective actions was not provided, as they are still ongoing.
The adequacy of your firm’s response dated August 28, 2025, cannot be determined at this time. Your firm’s response dated August 28, 2025, is a periodic update and did not include any additional new information.
The adequacy of your firm’s response dated October 29, 2025, cannot be determined at this time. Your firm’s response dated October 29, 2025, noted that your firm has a three-phase plan to address the reporting issue. However, documentation of the completion of these corrective actions was not provided, as they are still ongoing.
In addition, the inspection revealed that your firm failed to adequately develop, maintain, and implement written MDR procedures as required by 21 CFR 803.17(a)(1). For example, during the inspection, your firm presented a document titled “Guidelines for FDA Reporting”, SOP 13.1, Rev. A, dated 2023-10-23, as its MDR procedure. After reviewing the procedure, we conclude that the procedure does not establish internal systems that provide for timely and effective identification, communication, and evaluation of events that may be subject to MDR requirements, as required by 21 CFR 803.17(a)(1). For example, there are inadequate definitions of what constitutes a reportable event under 21 CFR Part 803. The fact that the procedure does not include a definition from 21 CFR 803.3 for the term “cause or contributed” may lead your firm to make an incorrect reportability decision when evaluating a complaint that may meet the criteria for reporting under 21 CFR 803.50(a).
Your firm’s response dated August 28, 2025, appears to be adequate. In the response, your firm included a copy of its revised MDR procedure titled “Guidelines for FDA Reporting”, Documents Number: SOP 13.1, Rev. B, dated 2025-07-16, along with staff training records. Upon review, the revised procedures have adequately addressed the deficiency described above.
Corrections and Removals Violation(s)
Our inspection also revealed that your firm’s iLet Dosing Decision Software and the iLet ACE Pump are misbranded under section 502(t)(2) of the Act, 21 U.S.C. § 352(t)(2), in that your firm failed or refused to furnish material or information respecting the device that is required by or under section 519 of the Act, 21 U.S.C. § 360i. 21 CFR Part 806 – Medical Devices; Reports of Corrections and Removals was promulgated under section 519 of the Act, among other provisions. Significant violations include, but are not limited to, the following:
Failure to submit to the FDA within 10 working days of initiating a correction or removal a report required by 21 CFR 806.10. For example:
A. Your firm discovered that the iLet Dosing Decision Software had failures regarding glucose values that were 5 minutes old (delayed readings), instead of using new readings as expected. The iLet Dosing Decision Software autonomously determines and commands an increase, decrease, maintenance, or suspension of all basal doses of insulin and autonomously determines and commands correction doses of insulin based on glucose readings, and it autonomously determines, and commands meal doses of insulin based on meal announcements. Use of the delayed glucose readings resulted in your iLet Dosing Decision Software not performing as intended, not dosing insulin to the patient and patient experiencing elevated blood glucose levels that presents a risk to health. Your firm implemented a software change/release version 1.4.4 to mitigate the risk to health posed by your iLet Dosing Decision Software. The new software version was uploaded to the cloud and made available to the customers for download on 4/5/2024. This action constitutes a medical device correction or removal initiated to reduce a risk to health posed by your device or remedy a violation of the Act caused by your device which may present a risk to health, under 21 CFR 806.10(a). You have not already provided this information as set forth in 21 CFR 806.10(f) (see 21 CFR 806.10(a)(2)), nor was the correction or removal action exempt from the reporting requirements under 21 CFR 806.1(b) (see 21 CFR 806.10(a)(2)). You were therefore required to submit a Report of Correction or Removal to FDA within 10 working days of initiation, under 21 CFR 806.10(b).
B. Your firm discovered that the iLet ACE Pump had cybersecurity vulnerability for the Limited Access feature of the iLet Bionic Pancreas System, which is used as a security measure to prevent unwanted access to the pump controls. When either the lockscreen or Limited Access Passcode screen is viewed on the iLet display, other icons are present and active, and
(b)(4)
. This results in unsecured access to change settings, including stopping insulin delivery or giving boluses inappropriately, both of which present a risk to health. Your firm implemented a software fix via DCO #3203 and released Software Version 1.4.3 on 3/26/2024. Beta Bionics sent an email to all customers on 4/1/2024, titled “iLet Software Update”, notifying them that Beta Bionics, Inc. released an iLet Bionic Pancreas Software update. This action constitutes a medical device correction or removal initiated to reduce a risk to health posed by the device or remedy a violation of the Act caused by the device which may present a risk to health, under 21 CFR 806.10(a). You have not already provided this information as set forth in 21 CFR 806.10(f) (see 21 CFR 806.10(a)(2)), nor was the correction or removal action exempt from the reporting requirements under 21 CFR 806.1(b) (see 21 CFR 806.10(a)(2)). You were therefore required to submit a Report of Correction or Removal to FDA within 10 working days of initiation, under 806.10(b).
Your firm’s responses to the FDA-483, dated July 18, 2025, August 29, 2025, and October 29, 2025, are not adequate. For the issue related to delayed glucose readings described in paragraph A above, you categorized your action as a device enhancement, stating that the change was to improve a non-violative device’s safety or performance. Even if you categorized the software update as a “device enhancement,” the evidence still indicates that a report of correction or removal was required to have been submitted to FDA because you initiated the correction (i.e., updated the software) in order to reduce a risk to health posed by the device (i.e., inaccurate insulin dosing). The fact that the issue might have also involved a third-party CGM does not change the fact that you initiated the correction to reduce a risk to health posed by your device. Furthermore, there is no evidence that you designed and tested the iLet device to function with the particular CGM at issue.
For the issue related to the cybersecurity vulnerability for the Limited Access feature described in paragraph B above, your firm alleges that the issue is non-reportable. We do not agree with this assessment. The evidence indicates that a report of correction or removal was required to have been submitted to FDA because you initiated the correction (i.e., updated the software) in order to reduce a risk to health posed by the device (i.e., prevent unsecured access to the pump controls).
In addition, regarding your statement that your firm was conducting a Class III recall, we note that a recall’s classification is assigned by FDA, not the recalling firm (e.g., 21 CFR 7.3(m) and 7.41(b)), and that conducting a voluntary recall does not exempt a firm from the requirement to submit a report of correction or removal under Part 806 (e.g., 21 CFR 806.10(a)(2)). As explained above, you were required to submit a report of correction or removal to FDA.
You have not submitted Reports of Correction or Removal to FDA as of 01/15/2026 for either of the failures listed above.
Your firm should take prompt action to address any violations identified in this letter. Failure to adequately address this matter may result in regulatory action being initiated by the FDA without further notice. These actions include, but are not limited to, seizure, injunction, and civil money penalties.
Other federal agencies may take your compliance with the FD&C Act and its implementing regulations into account when considering the award of federal contracts. Additionally, should FDA determine that you have Quality System regulation violations that are reasonably related to premarket approval applications for Class III devices, such devices will not be approved until the violations have been addressed. Should FDA determine that your devices or facilities do not meet the requirements of the Act, requests for Certificates to Foreign Governments (CFG) may not be granted.
Please notify this office in writing within fifteen business days from the date you receive this letter of the specific steps your firm has taken to address the noted violations, as well as an explanation of how your firm plans to prevent these violations, or similar violations, from occurring again. Include documentation of the corrections and/or corrective actions (which should address systemic problems) that your firm has taken. If your firm’s planned corrections and/or corrective actions will occur over time, please include a timetable for implementation of those activities. If corrections and/or corrective actions cannot be completed within fifteen business days, state the reason for the delay and the time within which these activities will be completed. Your firm’s response should be comprehensive and address any violations included in this Warning Letter. If you believe that your products are not in violation of the FD&C Act, include your reasoning and any supporting information for our consideration as part of your response.
Your firm’s response should be sent via email to CDRHEnforcement@fda.hhs.gov. Please include in the subject line, “
CMS Case 717927
” when replying. If you have any questions about the contents of this letter, please contact: Shaquenta Perkins at shaquenta.perkins@fda.hhs.gov.
Finally, you should know that this letter is not intended to be an all-inclusive list of the violations at your firm’s facility or concerning your firm’s devices. It is your firm’s responsibility to ensure compliance with applicable laws and regulations administered by FDA. The specific violations noted in this letter and in the Inspectional Observations, FDA 483, issued at the close of the inspection may be symptomatic of serious problems in your firm’s manufacturing and quality management systems. Your firm should investigate and determine the causes of any violations and take prompt actions to address any violations and bring the products into compliance.
Sincerely,
/S/
Barbara C. Marsden
Acting Director
Office of Regulatory Programs
Office of Product Evaluation and Quality
Center for Devices and Radiological Health
Content current as of:
02/24/2026
Regulated Product(s)
Medical Devices