Michael Leslie PEGG · Prevention of Future Deaths report

On 28 July 2023 I commenced an investigation and opened an inquest into the death of Michael Leslie PEGG. The investigation concluded at the end of the inquest on 23 January 2024

The conclusion of the inquest was that Mr. Pegg “died from natural causes.”

In answer to the questions “when, where and how did Mr. Pegg come by his death?”, I recorded as follows:

“On 13.1.23 Michael Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after suffering two significant seizures at home earlier that morning. Early the following morning he suffered a significant deterioration in his condition and developed pneumonia. Despite treatment, he continued to decline and died in hospital on 15.1.23.”

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.
2) Although in this case, I was unable to conclude that the above omissions in steroid treatment probably caused or contributed to Mr. Pegg’s death, it was nonetheless concerning to hear that none of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case. Unless action is taken to ensure clinicians employed by the Trust are aware of, and able to apply these Guidelines, there remains a risk that another patient with adrenal insufficiency may die in similar circumstances;
3) For a substantial part of his time at Worcestershire Royal Hospital, Mr. Pegg was being treated in a bed in a corridor in the Emergency Department, and then in the Majors Overflow area, both busy, crowded and noisy areas ill-suited to the proper treatment of patients. In his evidence to the inquest about trying to ensure that the Trust’s staff are aware of these Guidelines, Dr Raven told the inquest:
“As long as we still have crowded settings, it is difficult to provide assurances that these guidelines will be followed, for example because we have a high turnover of locum clinicians and agency nursing staff.”
It is particularly concerning to hear that patients’ wellbeing may be put at risk because a hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines.
It is perhaps unfair to put responsibility for rectifying this situation solely at the door of the Worcestershire Acute Hospitals NHS Trust, which is why this report is also being sent to NHS England and Health Education England.