Robin Keith Brett · Prevention of Future Deaths report

On 17/06/2014 I commenced an investigation into the death of Robin Keith Brett, 18 . The investigation concluded at the end of the inquest on 22 December 2015. The conclusion of the inquest was Robin died from natural causes contributed to by neglect.

Robin was an 18 year old man who was born with congenital adrenal hyperplasia. This necessitated daily steroid replacement with a need to supplement the daily dose with IV steroids if he became unwell.

He was admitted to the Great Western Hospital on 13 June 2014 with history of severe constipation and in an addisonian crisis. This was initially treated appropriately but he was not given the regular steroids that had been prescribed by the doctors. This was an error.

When he died at 0430hrs on 14 June 2014 he had not had any steroids since 1200 hrs on 13 June 2014. This significantly weakened his ability to cope with the strain the constipation put on his body.

The evidence that I heard at Inquest showed that any patient on long term steroids for whatever reason must not have their steroids stopped suddenly, if they do there is a likelihood of an addisonian crisis and death.

This patient was prescribed steroids appropriately but the nursing staff failed to notice a dose of steroids had been missed. There is no system on the paper drug chart or the electronic prescribing system for alerting medical staff to patients being on long term steroids.