Recurring concern

Failure to provide urgent support and safety-netting for adrenal crisis risk

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First reported 19 Apr 2023•Latest report 26 Jan 2024

Definition

What this concern includes

Includes failures specifically tied to adrenal-crisis prevention or response, including records, recognition, emergency treatment, clinical oversight and patient safety-netting.

Not included

Generic failures to provide safety-netting where no medication-related crisis risk is identified.
Generic documentation, staffing, training or communication deficiencies not specifically tied to medication-related crisis management.
Failures concerning delayed access or escalation for clinical urgency that are unrelated to essential medication interruption or medication-dependent crisis risk.

Reports: 2
Individual concerns: 5
Date range: 2023–2024
Stated actions: 29

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England2

Worcestershire Acute Hospitals NHS Trust2

Association of Ambulance Chief Executives1

National Institute for Health and Care Excellence1

Society For Endocrinology1

West Midlands Ambulance Service University NHS Foundation Trust1

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.

26 Jan2024
Worcestershire
Concerns raised1
1. Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
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 9
1. 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 completed
2. 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 completed
3. 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 progress
1. Action
  Incorporate steroids and other time-critical medications into the Emergency Department electronic patient record.
  Stated by Worcestershire Acute Hospitals NHS TrustStated planned
2. 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 progress
3. 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 planned
4. 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 progress
5. Action
  Publish guidance for preventing and managing adrenal insufficiency emergencies in adults.
  Stated by NHS EnglandStated completed
6. Action
  Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
  Stated by NHS EnglandStated completed
AI-generated summary

Michael Leslie PEGG · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael Leslie Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after two significant seizures and died there on 15 January 2023 following deterioration and pneumonia. The report raised concerns that steroid treatment fell far short of relevant NICE guidelines, that staff awareness and application of the guidelines were insufficient, and that crowded treatment areas created difficulties in providing appropriate care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
Wider context from the report
“1) Over the two days that Mr. Pegg was at Worcestershire Royal Hospital, those treating him failed to apply the NICE guidelines which relate to the treatment of those with adrenal insufficiency conditions who are being treated for intercurrent illness. ████████, who conducted the Trust’s serious incident investigation into these events, told the inquest: “There was a policy in place for administering steroids, as per the 2020 NICE guidelines – this advises: (a) double dosing of oral steroids in cases of intercurrent illness until 48 hours after recovery (also known as Sick Day rule 1); (b) if [the patient has ] significant trauma, prolonged vomiting or diarrhoea, then 100mg IV hydrocortisone [ should be administered ]; (c) if suspected adrenal crisis, 100mg IV hydrocortisone immediately.” In fact, the steroid treatment provided to Mr. Pegg during this admission fell far short of those Guidelines, in that: (a) He only received one double dose of his oral hydrocortisone medication, which he was usually required to take twice a day; (b) He received no doses at all ( double or standard ) of his oral prednisolone medication, which he was usually required to take once a day; (c) Although he did eventually receive a 100mg dose of IV hydrocortisone on 14.1.23, this should have been given much earlier that day when his condition seriously deteriorated. ”
Source location
Michael Leslie PEGG · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use the updated Emergency Department adult patient document, which automatically includes highlighted steroid replacement as a time-critical medication for all adults.

Verbatim wording from the response
“several occasions since Mr Pegg’s sad death. Discussions included the importance of the adult patient document in the Emergency Department which was updated in June 2023. This now includes a time critical medications (highlighted steroid replacement) (please see appendix 1 attached). This is automatically included for all adults presenting to the Emergency Department.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Circulate steroid replacement safety materials to Emergency and Medical staff and display them in the Emergency Department handover area.

Verbatim wording from the response
“• A “detect and reflect” document and “time critical medication safety flash” have been circulated to all Emergency and Medical staff to raise awareness of the need for steroid replacement therapy (appendix 2, 3). These are displayed in the Emergency Department handover area.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Highlight steroid replacement in Emergency Department handovers and repeat the messaging to maintain medical staff awareness.

Verbatim wording from the response
“• Steroid replacement (and other time critical meds) has been highlighted in effective handover in ED in 2023 and will be repeated (appendix 4) to raise and maintain awareness for all medical staff working in the ED.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Incorporate steroids and other time-critical medications into the Emergency Department electronic patient record.

Verbatim wording from the response
“• The Trust is due to move to an electronic patient record in the Emergency Department in Autumn 2024 – time critical medications including steroids are due to be incorporated into this.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Participate in the Royal College of Emergency Medicine audit of prescribing and administration of time-critical medicines, including steroids.

Verbatim wording from the response
“• The Emergency Departments on both sites are participating in a Royal College of Emergency Medicine audit looking at the prescribing and administration of time critical medicines, including steroids. This audit will provide a “benchmark” for the Trust and also highlight areas where further improvement is required. The audit is still in data collection phase but results will be available later in the year.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Have the Acting Chief Medical Officer highlight steroid replacement during induction for new doctors rotating into the hospitals.

Verbatim wording from the response
“• The Acting Chief Medical Officer will be attending the Induction for new doctors in August in order to highlight this area of focus for the Trust for all junior doctors rotating into our hospitals.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Prioritise adrenal insufficiency and steroid replacement for Medical Examiner review, triggering further case review when concerns are identified.

Verbatim wording from the response
“• The Medical Examiners, at the request of the Trust, are working with Adrenal Insufficiency/Steroid Replacement as one of their high priority conditions which means that any concerns identified with steroid replacement will trigger further case review. The focus therefore remains on this area and will continue to be so until we are fully assured that our processes for identifying and managing this condition are effective.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish guidance for preventing and managing adrenal insufficiency emergencies in adults.

Verbatim wording from the response
“NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.”

Source location
Response from NHS England
Page 1 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.

Verbatim wording from the response
“NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.”

Source location
Response from NHS England
Page 1 · response
Published 7 June 2024
Open published response
19 Apr2023
Worcestershire
Concerns raised4
1. Call-handler pathway failing to consider adrenal crisis risk after trauma
2. National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
3. Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
1. Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
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 20
1. 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 progress
2. 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 progress
3. 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 completed
1. Action
  Engage stakeholders and monitor emerging evidence and guidelines on emergency steroid replacement in pre-hospital care.
  Stated by NHS EnglandStated planned
2. Action
  Engage Medical Priority Dispatch System suppliers to review their processes for assessing adrenal insufficiency.
  Stated by NHS EnglandStated planned
3. Action
  Ensure trauma and physiological stress topics are covered in the NICE adrenal insufficiency guideline.
  Stated by Society For EndocrinologyStated planned
4. Action
  Publish guidance for preventing and managing adult adrenal insufficiency emergencies.
  Stated by NHS EnglandStated completed
5. Action
  Revise JRCALC guidance to emphasize steroid administration after trauma or physiological stress.
  Stated by Association of Ambulance Chief ExecutivesStated in progress
6. Action
  Develop steroid-dependent patient guidance with input from patient representatives and clinical advisers.
  Stated by Association of Ambulance Chief ExecutivesStated completed
7. 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 completed
8. 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 completed
9. 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 progress
10. Action
  Provide individual feedback and require reflection by clinicians involved in the case.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
11. 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 completed
12. Action
  Provide recurring adrenal insufficiency teaching to Trauma and Orthopaedic junior doctors through induction, three times annually.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
13. 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 completed
14. 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 completed
15. 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 completed
16. Action
  Update the Trauma and Orthopaedic admission document to include steroid-management prompts.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
17. Action
  Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
  Stated by NHS EnglandStated completed
Respondent positions 4
1. Position
  Ambulance hydrocortisone availability and authorised personnel should not prevent administration during trauma or injury.
  Stated by Society For EndocrinologyDisputes the concern
1. 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 act
2. 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 sufficient
3. 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 remit
AI-generated summary

DAVID ERNEST MASON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Call-handler pathway failing to consider adrenal crisis risk after trauma
Wider context from the report
“2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately. This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety-netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at WMAS. ”
Source location
DAVID ERNEST MASON · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report
“1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress. Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. It is my understanding that a new guideline in respect of managing the treatment of adrenal insufficiency is currently being developed by NICE. Consideration of these matters should be included as part of guideline development. ”
Source location
DAVID ERNEST MASON · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
Wider context from the report
“1) Evidence heard at the inquest demonstrated that no clinician involved in providing care to Mr Mason (in both the emergency department and the surgical trauma department) appreciated that, as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy, to prevent the development of an acute adrenal crisis. ”
Source location
DAVID ERNEST MASON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report
“2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are on the same page as advice to patients and families for long-term condition management) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress. ”
Source location
DAVID ERNEST MASON · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Liaise with JRCALC to align ambulance protocols and clarify additional oral or intramuscular hydrocortisone for trauma or injury.

Verbatim wording from the response
“The Society for Endocrinology will have opportunity to review this when it is shared with stakeholders and provide comments. Also, members of the Society for Endocrinology are on the committee writing the guidelines and will ensure these topics are covered. In terms of Ambulance service, JRCALC has protocols advising on the management of patients with adrenal insufficiency. ████████ is liaising with them, at present and we will ensure all protocols align and are clear about the need to give additional oral or IM hydrocortisone in trauma/injury. JRCALC guidelines state anyone can give IM hydrocortisone and we are aware that there is an issue around paramedics and technicians being reminded both groups can administer emergency treatment. This is important as different types of ambulance have different health care professionals working on them.”

Source location
Response from Society for Endocrinology
Page 1 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with ambulance, 999 and 111 services through NHSE to include steroid emergency information in call-handler triage and support category 2 ambulance dispatch.

Verbatim wording from the response
“In terms of the NHSE steroid emergency card, the wording states injury/shock. We will continue our work with both ambulance services and 999/111 services via NHSE patient safety team to ensure this is on the triage information to call handlers so a category 2 ambulance can be sent. All ambulances carry hydrocortisone, and both paramedics and ambulance technicians are able to administer IM hydrocortisone so this should not be a blocker to administration. JRCALC may be able to address this in their guidelines. It is possible thatmore work is needed to disseminate the information available and we can continue working with RCP Patient Safety Committee and NHSE Patient Safety team in this regard. We will also update our resources accordingly.”

Source location
Response from Society for Endocrinology
Page 1 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Raise the NHS Pathways concern about adrenal-insufficiency risks following trauma on the clinical concern log.

Verbatim wording from the response
“Response Calls to 999 are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP).”

Source location
Response from West Midlands Ambulance Service
Page 3 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Engage stakeholders and monitor emerging evidence and guidelines on emergency steroid replacement in pre-hospital care.

Verbatim wording from the response
“However, having learned of this case, NHS Pathways will engage with its stakeholders and monitor emerging evidence and guidelines with respect to emergency steroid replacement therapy in the pre-hospital setting, with a view to making system changes where appropriate in accordance with the governance framework. If it is established that system-wide changes are required, NHS Pathways will work closely with colleagues in the ambulance sector to ensure safety-netting advice is appropriate.”

Source location
Response from NHS England
Page 2 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Engage Medical Priority Dispatch System suppliers to review their processes for assessing adrenal insufficiency.

Verbatim wording from the response
“NHS England will also engage with Medical Priority Dispatch System, the suppliers of the alternative telephone and digital triage system used by ambulance services in England, to review their processes for assessing adrenal insufficiency.”

Source location
Response from NHS England
Page 2 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ensure trauma and physiological stress topics are covered in the NICE adrenal insufficiency guideline.

Verbatim wording from the response
“Trauma and physiological stress are within scope for the NICE guideline on adrenal insufficiency currently in development. There is representation from paramedics, Emergency Medicine, General Practice and lay members on the committee so the guidelines will cover pre hospital care. Once guidelines are published there is a plan for another round of communications to disseminate the information.”

Source location
Response from Society for Endocrinology
Page 1 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish guidance for preventing and managing adult adrenal insufficiency emergencies.

Verbatim wording from the response
“NHS England has worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting with adrenal insufficiency or acute medicine setting.”

Source location
Response from NHS England
Page 3 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revise JRCALC guidance to emphasize steroid administration after trauma or physiological stress.

Verbatim wording from the response
“Your first matter of concern relates to our ‘JRCALC guidance’ not being sufficiently clear that patients who may have suffered trauma or physiological stress also require steroid treatment, to prevent an adrenal crisis. The JRCALC guidelines have been in existence since the 1990’s but it was only in 2022 that we decided that a standalone guideline for steroid dependent patients was needed. We have decided that the wording and emphasis on administering steroids to patients who suffer trauma or physiological stress could have more emphasis placed on it, so we are now in the process of revising our guidance.”

Source location
Response from Association of Ambulance
Page 1 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop steroid-dependent patient guidance with input from patient representatives and clinical advisers.

Verbatim wording from the response
“Your first matter of concern relates to our ‘JRCALC guidance’ not being sufficiently clear that patients who may have suffered trauma or physiological stress also require steroid treatment, to prevent an adrenal crisis. The JRCALC guidelines have been in existence since the 1990’s but it was only in 2022 that we decided that a standalone guideline for steroid dependent patients was needed. We have decided that the wording and emphasis on administering steroids to patients who suffer trauma or physiological stress could have more emphasis placed on it, so we are now in the process of revising our guidance.”

Source location
Response from Association of Ambulance
Page 1 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Cover identification, emergency management and prevention of adrenal crisis during trauma and other physiological stress in the new guideline.

Verbatim wording from the response
“We have reflected on the circumstances surrounding Mr Mason’s death, and the concerns raised in your report. We note your suggestion that the issues raised in your report should be considered in the development of our new guideline on adrenal insufficiency, particularly that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress.”

Source location
Response from NICE
Page 1 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include two paramedic co-optees and relevant emergency-care health professionals on the adrenal insufficiency guideline committee.

Verbatim wording from the response
“I can confirm that the scope of this guideline covers adrenal crisis including identification and emergency management and preventing adrenal crisis during periods of physiological stress, which includes trauma. Membership of the guideline committee recruited for this topic includes two paramedic co-optees, as well as health professionals who see people with adrenal crisis or who are at risk of adrenal crisis in the emergency department.”

Source location
Response from NICE
Page 1 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue liaising with NHSE and the Royal College of Emergency Medicine to support appropriate additional hydrocortisone for patients with adrenal insufficiency.

Verbatim wording from the response
“We are aware that, in the current climate with pressures on ambulance services and emergency departments, there may be delays in patients with adrenal insufficiency being managed appropriately. We will continue to liaise with the NHSE patient safety team and Royal College of Emergency Medicine to ensure that patients with adrenal insufficiency are given additional hydrocortisone in the appropriate way to prevent further deaths.”

Source location
Response from Society for Endocrinology
Page 2 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide individual feedback and require reflection by clinicians involved in the case.

Verbatim wording from the response
“1. In order to raise awareness and educate clinicians, the following actions have been taken. Individual feedback was given and reflection undertaken by clinicians involved in July 2022 (appendix 1). On the 9th May 2023 at the Trauma & Orthopaedic (T&O) Governance meeting attended by 33 multidisciplinary staff including T&O Consultants this case was discussed and reflected upon (appendix 2). A teaching session was delivered by the Deputy Chief Medical Officer to 40+ Surgical trainees at a Regional Teaching Session on the 9th May 2023 (appendix 3). A teaching session highlighting the risk of adrenal insufficiency for T&O Junior Doctors delivered by a consultant Anaesthetist is now given three times per year as part of the induction programme (appendix 4).”

Source location
Response from Worcestershire Acute Hospitals
Page 2 · response
Published 26 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver teaching on the case and adrenal insufficiency risks to surgical trainees at a regional teaching session.

Verbatim wording from the response
“1. In order to raise awareness and educate clinicians, the following actions have been taken. Individual feedback was given and reflection undertaken by clinicians involved in July 2022 (appendix 1). On the 9th May 2023 at the Trauma & Orthopaedic (T&O) Governance meeting attended by 33 multidisciplinary staff including T&O Consultants this case was discussed and reflected upon (appendix 2). A teaching session was delivered by the Deputy Chief Medical Officer to 40+ Surgical trainees at a Regional Teaching Session on the 9th May 2023 (appendix 3). A teaching session highlighting the risk of adrenal insufficiency for T&O Junior Doctors delivered by a consultant Anaesthetist is now given three times per year as part of the induction programme (appendix 4).”

Source location
Response from Worcestershire Acute Hospitals
Page 2 · response
Published 26 April 2023
Open published response
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How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide recurring adrenal insufficiency teaching to Trauma and Orthopaedic junior doctors through induction, three times annually.

Verbatim wording from the response
“1. In order to raise awareness and educate clinicians, the following actions have been taken. Individual feedback was given and reflection undertaken by clinicians involved in July 2022 (appendix 1). On the 9th May 2023 at the Trauma & Orthopaedic (T&O) Governance meeting attended by 33 multidisciplinary staff including T&O Consultants this case was discussed and reflected upon (appendix 2). A teaching session was delivered by the Deputy Chief Medical Officer to 40+ Surgical trainees at a Regional Teaching Session on the 9th May 2023 (appendix 3). A teaching session highlighting the risk of adrenal insufficiency for T&O Junior Doctors delivered by a consultant Anaesthetist is now given three times per year as part of the induction programme (appendix 4).”

Source location
Response from Worcestershire Acute Hospitals
Page 2 · response
Published 26 April 2023
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How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share a Lesson of the Week on adrenal insufficiency through governance teams and Trust communication and incident-management channels.

Verbatim wording from the response
“A Lesson of the Week was shared on 25th May 2023 (appendix 5), with Governance teams to disseminating it through Divisions, in the Trust “Worcestershire Weekly”, Datix Incident management system and the Trust Intranet page.”

Source location
Response from Worcestershire Acute Hospitals
Page 2 · response
Published 26 April 2023
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How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend the Trust guideline to advise on additional steroid replacement for admitted Emergency Department patients at risk from physiological stress and pain.

Verbatim wording from the response
“2. The Trust guideline, based on National guidance, has been amended to include clear advice for all patients in the Emergency Departments who require admission (appendix 6). Following discussion with our Endocrinology and Emergency Department teams, it was felt that this would be the most effective way of ensuring that clinicians were aware of the need for additional steroid replacement therapy for patients at risk of adrenal crisis due to physiological stress and pain.”

Source location
Response from Worcestershire Acute Hospitals
Page 2 · response
Published 26 April 2023
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How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement Emergency Department admission-document prompts for time-critical steroid medications and consideration of increased steroid doses.

Verbatim wording from the response
“4. Changes have been made to the ED admission documents, implemented 6th June 2023, to include prompts on time critical medications, including steroids, and to consider increasing the dose of steroids (appendix 7). The T&O admission document, as discussed at the Inquest, was updated in October 2022 to include Steroid Management prompts (appendix 8).”

Source location
Response from Worcestershire Acute Hospitals
Page 2 · response
Published 26 April 2023
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How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the Trauma and Orthopaedic admission document to include steroid-management prompts.

Verbatim wording from the response
“4. Changes have been made to the ED admission documents, implemented 6th June 2023, to include prompts on time critical medications, including steroids, and to consider increasing the dose of steroids (appendix 7). The T&O admission document, as discussed at the Inquest, was updated in October 2022 to include Steroid Management prompts (appendix 8).”

Source location
Response from Worcestershire Acute Hospitals
Page 2 · response
Published 26 April 2023
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How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.

Verbatim wording from the response
“NHS England has worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting with adrenal insufficiency or acute medicine setting.”

Source location
Response from NHS England
Page 3 · response
Published 26 April 2023
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How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ambulance hydrocortisone availability and authorised personnel should not prevent administration during trauma or injury.

Verbatim wording from the response
“In terms of the NHSE steroid emergency card, the wording states injury/shock. We will continue our work with both ambulance services and 999/111 services via NHSE patient safety team to ensure this is on the triage information to call handlers so a category 2 ambulance can be sent. All ambulances carry hydrocortisone, and both paramedics and ambulance technicians are able to administer IM hydrocortisone so this should not be a blocker to administration. JRCALC may be able to address this in their guidelines. It is possible thatmore work is needed to disseminate the information available and we can continue working with RCP Patient Safety Committee and NHSE Patient Safety team in this regard. We will also update our resources accordingly.”

Source location
Response from Society for Endocrinology
Page 1 · response
Published 26 April 2023
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How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
WMAS cannot change the nationally required NHS Pathways triage system used to assess 999 calls.

Verbatim wording from the response
“Response Calls to 999 are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP).”

Source location
Response from West Midlands Ambulance Service
Page 3 · response
Published 26 April 2023
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How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing NHS Pathways design is considered sufficient because extra adrenal-insufficiency questioning could delay care or create confusion.

Verbatim wording from the response
“The majority of calls taken using NHS Pathways are handled by a highly trained but non-clinical Health Advisor. Health Advisors (as per the NHS Pathways Provider Licence) should have access to support from clinicians to support safe call-handling. Even though thorough training is provided, it is not within the remit of the Health Advisor to be trained in, or understand more complex medical elements, such as in this case. Indeed, such enquiry and added confusion delays the management of the case and triaging process. It is for these reasons that questions on past medical history or pharmacology are utilised sparingly across the system, and only where it is deemed that a clear understanding can be sought.”

Source location
Response from NHS England
Page 2 · response
Published 26 April 2023
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How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
AACE has no responsibility for changing the NHS Pathways system used to assess 999 calls in the West Midlands.

Verbatim wording from the response
“With regard to your second matter of concern about the advice given in ambulance control centres to people who call 999. Calls to 999 in the West Midlands region are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP) and therefore we have no responsibility for making changes to this system. We are aware from West Midlands ambulance service that the matter has been raised with NHSP. We are however aware of the development of an educational e learning package for call handlers so they have a better understanding and awareness of Addison’s disease and steroid dependent patients. The package will be trialled in Yorkshire and is being developed in conjunction with The Pituitary Foundation.”

Source location
Response from Association of Ambulance
Page 1 · response
Published 26 April 2023
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Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness

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

Concerns raised4

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

Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress

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.20

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Actions described in response 9

Actions described in response 20

Respondent positions 4