PFD report

Terence Bradfield · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 11 Mar 2019•Plymouth, Torbay and South Devon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised6

  1. Failure to provide stress-dose steroids
    Part of recurring concern: Unreliable prevention and response to adrenal crisis
  2. Failure to prescribe intravenous hydrocortisone when vomiting prevents oral steroid administration
    Part of recurring concern: Unsafe medication prescribing
  3. Failure to administer prescribed steroids
    Part of recurring concern: Failure to provide required medication promptly when clinically neededPart of recurring concern: Unsafe medication administration
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 clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide stress-dose steroids

Wider context from the report

“(1) They are : 1. Mr. Bradfield was not given his steroids on 2.12.13 2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting 3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital 4. The awareness and training of staff on the issue of steroid management. 5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013. 6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures . ”

Is this part of a recurring concern?

Yes — Unreliable prevention and response to 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to prescribe intravenous hydrocortisone when vomiting prevents oral steroid administration

Wider context from the report

“(1) They are : 1. Mr. Bradfield was not given his steroids on 2.12.13 2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting 3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital 4. The awareness and training of staff on the issue of steroid management. 5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013. 6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures . ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to administer prescribed steroids

Wider context from the report

“(1) They are : 1. Mr. Bradfield was not given his steroids on 2.12.13 2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting 3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital 4. The awareness and training of staff on the issue of steroid management. 5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013. 6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures . ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed; Unsafe medication administration.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a policy for steroid administration and use with multiple comorbidities

Wider context from the report

“(1) They are : 1. Mr. Bradfield was not given his steroids on 2.12.13 2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting 3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital 4. The awareness and training of staff on the issue of steroid management. 5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013. 6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures . ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate staff training and awareness on Nil by Mouth management for patients requiring regular medication

Wider context from the report

“(1) They are : 1. Mr. Bradfield was not given his steroids on 2.12.13 2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting 3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital 4. The awareness and training of staff on the issue of steroid management. 5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013. 6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures . ”

Is this part of a recurring concern?

Yes — Unreliable management of nil-by-mouth restrictions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate staff awareness and training on steroid management

Wider context from the report

“(1) They are : 1. Mr. Bradfield was not given his steroids on 2.12.13 2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting 3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital 4. The awareness and training of staff on the issue of steroid management. 5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013. 6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures . ”

Is this part of a recurring concern?

Yes — Unreliable prevention and response to adrenal crisis.

Open source report
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026