First reported 11 Jan 2016•Latest report 13 Aug 2024
Definition
What this concern includes
Includes failures in controls specifically dedicated to preventing or responding to adrenal crisis and steroid insufficiency, including staff recognition and knowledge, prompts or alerts for adrenal insufficiency or long-term steroid use, continuation of replacement steroids, emergency or stress-dose treatment, and escalation when symptoms suggest adrenal crisis.
Not included
Excludes generic staff training, communication, prescribing or medication-administration deficiencies unless they directly concern adrenal insufficiency, steroid dependence or adrenal-crisis prevention and response.
Excludes routine steroid treatment or monitoring for conditions without an adrenal-insufficiency or adrenal-crisis safety connection.
Excludes confirmed adrenal-crisis treatment failures occurring after the condition was reliably recognised and appropriate emergency response was initiated.
Excludes unrelated medication omissions, clinical deterioration or emergency-service failures where steroid insufficiency or adrenal crisis is not the material safety concern.
Reports
6
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2016–2024
First to latest report issue date
Stated actions
46
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England4
Association of Ambulance Chief Executives2
Worcestershire Acute Hospitals NHS Trust2
Great Western Hospitals NHS Foundation Trust1
National Institute for Health and Care Excellence1
North East Ambulance Service NHS Foundation Trust1
Royal College of General Practitioners1
Society For Endocrinology1
University Hospitals Plymouth NHS Trust1
West Midlands Ambulance Service University NHS Foundation Trust1
NHS trust5
Executive non-departmental public body4
Health-sector membership body2
Health professional body1
Registered charity1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Teesside and Hartlepool
Concerns raised3
Insufficient awareness of Steroid Emergency Cards
Insufficient usage of Steroid Emergency Cards
Lack of Ambulance Service staff understanding of steroid medication importance and required actions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Include an image of the NHS steroid emergency card in JRCALC steroid-dependent patient guidance to raise awareness among ambulance clinicians.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 14 August 2024.
Action
Issue a National Patient Safety Alert introducing the Steroid Emergency Card to support early recognition and treatment of adult adrenal crisis.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 August 2024.
Action
Publish an Addison’s Self Help Group website link and conduct social-media awareness activity about steroid emergency cards.
Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2024.
Action
Review NHS Pathways content and classify callers declaring a Steroid Emergency Card as complex calls requiring clinical input.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 August 2024.
Action
Develop and deliver education materials on steroid-dependent patients and adrenal insufficiency, including two clinical alerts.
Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2024.
Action
Disseminate an adrenal-crisis training event and additional adrenal-insufficiency and steroid-dependency resources through corporate communications channels.
Stated by North East Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2024.
Action
Develop a time-critical-medications training module, including steroids, for statutory and mandatory training.
Stated by North East Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2024.
Action
Include the time-critical-medications module in statutory and mandatory training delivered in 2025/2026.
Stated by North East Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2024.
Action
Roll out a refresher bulletin for Health Advisors on adrenal insufficiency, Addison’s disease and adrenal crisis, and monitor staff completion and understanding.
Stated by North East Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The North East and North Cumbria Integrated Care Board will respond directly to the Coroner regarding the concerns raised.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Care Quality Commission is responsible for ensuring NHS providers implement the actions required by the National Patient Safety Alert.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
All Trusts are understood to comply with the National Patient Safety Alert on steroid emergency cards.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Education and training of ambulance paramedics is outside the respondent’s remit.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Association of Ambulance Chief Executives is the appropriate organisation to provide further information on ambulance-service concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Health Advisors are not within the remit to understand complex medical issues such as steroid insufficiency during call triage.
Stated by North East Ambulance Service NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Worcestershire
Concerns raised2
Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency
Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Use the updated Emergency Department adult patient document, which automatically includes highlighted steroid replacement as a time-critical medication for all adults.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Circulate steroid replacement safety materials to Emergency and Medical staff and display them in the Emergency Department handover area.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Highlight steroid replacement in Emergency Department handovers and repeat the messaging to maintain medical staff awareness.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 June 2024.
Action
Incorporate steroids and other time-critical medications into the Emergency Department electronic patient record.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 7 June 2024.
Action
Participate in the Royal College of Emergency Medicine audit of prescribing and administration of time-critical medicines, including steroids.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 June 2024.
Action
Have the Acting Chief Medical Officer highlight steroid replacement during induction for new doctors rotating into the hospitals.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 7 June 2024.
Action
Prioritise adrenal insufficiency and steroid replacement for Medical Examiner review, triggering further case review when concerns are identified.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 June 2024.
Action
Publish guidance for preventing and managing adrenal insufficiency emergencies in adults.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Liverpool and the Wirral
Concerns raised1
Failure of the SCR model to automatically flag long-term steroid use for appropriate monitoring
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised6
Call-handler pathway failing to consider adrenal crisis risk after trauma
National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
Absence of adrenal insufficiency prompts in emergency department and clerking documentation
Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.28
Action
Liaise with JRCALC to align ambulance protocols and clarify additional oral or intramuscular hydrocortisone for trauma or injury.
Stated by Society For EndocrinologyStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2023.
Action
Work with ambulance, 999 and 111 services through NHSE to include steroid emergency information in call-handler triage and support category 2 ambulance dispatch.
Stated by Society For EndocrinologyStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2023.
Action
Raise the NHS Pathways concern about adrenal-insufficiency risks following trauma on the clinical concern log.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Engage stakeholders and monitor emerging evidence and guidelines on emergency steroid replacement in pre-hospital care.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.
Action
Engage Medical Priority Dispatch System suppliers to review their processes for assessing adrenal insufficiency.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.
Action
Ensure trauma and physiological stress topics are covered in the NICE adrenal insufficiency guideline.
Stated by Society For EndocrinologyStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.
Action
Publish guidance for preventing and managing adult adrenal insufficiency emergencies.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Revise JRCALC guidance to emphasize steroid administration after trauma or physiological stress.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2023.
Action
Develop steroid-dependent patient guidance with input from patient representatives and clinical advisers.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Cover identification, emergency management and prevention of adrenal crisis during trauma and other physiological stress in the new guideline.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Include two paramedic co-optees and relevant emergency-care health professionals on the adrenal insufficiency guideline committee.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Continue liaising with NHSE and the Royal College of Emergency Medicine to support appropriate additional hydrocortisone for patients with adrenal insufficiency.
Stated by Society For EndocrinologyStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2023.
Action
Provide individual feedback and require reflection by clinicians involved in the case.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Deliver teaching on the case and adrenal insufficiency risks to surgical trainees at a regional teaching session.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Provide recurring adrenal insufficiency teaching to Trauma and Orthopaedic junior doctors through induction, three times annually.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Share a Lesson of the Week on adrenal insufficiency through governance teams and Trust communication and incident-management channels.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Amend the Trust guideline to advise on additional steroid replacement for admitted Emergency Department patients at risk from physiological stress and pain.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Implement Emergency Department admission-document prompts for time-critical steroid medications and consideration of increased steroid doses.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Update the Trauma and Orthopaedic admission document to include steroid-management prompts.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Issue the National Patient Safety Alert requiring providers to prompt checks for adrenal-crisis risk and Steroid Emergency Cards.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Disseminate information through another communications round after the NICE guideline is published.
Stated by Society For EndocrinologyStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.
Action
Update Society resources on adrenal insufficiency and emergency hydrocortisone.
Stated by Society For EndocrinologyStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.
Action
Maintain a webpage providing resources to help healthcare teams develop adrenal insufficiency management resources.
Stated by Society For EndocrinologyStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Communicate updated adrenal-crisis and steroid-dependent-patient guidance to staff through clinical times and clinical notices.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Provide clinicians with access to JRCALC guidance through individual licenses and the JRCALC Plus app.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Disseminate relevant external clinical guidance, including steroid emergency-card guidance, through weekly staff briefings.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Publish an in-depth clinical-times article to improve clinicians’ knowledge of adrenal insufficiency and replacement steroid therapy.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Ambulance hydrocortisone availability and authorised personnel should not prevent administration during trauma or injury.
Stated by Society For EndocrinologyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
WMAS cannot change the nationally required NHS Pathways triage system used to assess 999 calls.
Stated by West Midlands Ambulance Service University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing NHS Pathways design is considered sufficient because extra adrenal-insufficiency questioning could delay care or create confusion.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
AACE has no responsibility for changing the NHS Pathways system used to assess 999 calls in the West Midlands.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Plymouth, Torbay and South Devon
Concerns raised2
Failure to provide stress-dose steroids
Inadequate staff awareness and training on steroid management
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Wiltshire and Swindon
Concerns raised2
Failure to detect missed steroid doses
Lack of alerts identifying patients on long-term steroids
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures in controls specifically dedicated to preventing or responding to adrenal crisis and steroid insufficiency, including staff recognition and knowledge, prompts or alerts for adrenal insufficiency or long-term steroid use, continuation of replacement steroids, emergency or stress-dose treatment, and escalation when symptoms suggest adrenal crisis.
