Concerns raised 8 Call-handler pathway failing to consider adrenal crisis risk after trauma View source National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress View source Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress View source Absence of adrenal insufficiency prompts in emergency department and clerking documentation View source Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress View source Unclear NHS England monitoring of compliance with National Patient Safety Alerts View source Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy View source Failure of internal investigation coordination and learning from patient-safety incidents View source See 5 more concerns
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
PFD Monitor interpretation Absence of adrenal insufficiency prompts in emergency department and clerking documentation
Wider context from the report “4) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency . Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
PFD Monitor interpretation Unclear NHS England monitoring of compliance with National Patient Safety Alerts
Wider context from the report “2) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. It is not clear what follow-up action is taken by NHS England in relation to monitoring of compliance by NHS Trusts following National Patient Safety Alerts being issued.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy
Wider context from the report “3) Evidence heard at the inquest (relating to the trauma/surgical department at WAHT) suggested that it is likely that many clinicians (including at consultant level) do not have a well-developed understanding of adrenal insufficiency and the crucial importance of administering replacement steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering an adrenal crisis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Society For Endocrinology; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigation coordination and learning from patient-safety incidents
Wider context from the report “4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle , which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason by WMAS.
” Open source report
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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
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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 Disseminate information through another communications round after the NICE guideline is published.
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
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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 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
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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 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
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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 Maintain a webpage providing resources to help healthcare teams develop adrenal insufficiency management resources.
Verbatim wording from the response “In order to support health and care providers, the Society for Endocrinology has set up a webpage with resources to help health care teams develop resources to support management of adrenal insufficiency. We will review this once NICE guidelines are written and ensure that pre-hospital care is covered more clearly. We would be happy to work with Worcestershire Acute Hospitals NHS Trust to review their materials if helpful.” Source location Response from Society for Endocrinology
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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 Society resources on adrenal insufficiency and emergency hydrocortisone.
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
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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
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations