David Mason
The coroner's concerns
1. lack of steroid replacement therapy for Addison's disease patients after trauma
“no clinician involved in providing care to Mr [name redacted] (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 [name redacted] required additional replacement steroid therapy, to prevent the development of an acute adrenal crisis”
2. lack of steroid replacement therapy for Addison's disease patients after trauma
“no clinician involved in providing pre-hospital care to Mr [name redacted] 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 [name redacted] required additional replacement steroid therapy, to prevent the development of an acute adrenal crisis”
Responses
2023-0125-Response-from-Association-of-Ambulance.pdf ↗· Association of Ambulance Chief Executives
2023-0125-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“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.”
2023-0125-Response-from-NICE.pdf ↗· Association of Ambulance Chief Executives
Stated action
“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.”
2023-0125-Response-from-Society-for-Endocrinology.pdf ↗· National Institute for Health and Care Excellence
Stated action
“recommend that all health and care providers ensure their organization has put processes in place to ensure the four actions on the National Patient Safety Alert have been addressed.”
2023-0125-Response-from-West-Midlands-Ambulance-Service.pdf ↗· West Midlands Ambulance Service University NHS Foundation Trust
2023-0125-Response-from-Worcestershire-Acute-Hospitals.pdf ↗· Worcestershire Acute Hospitals NHS Trust
Stated action · 9th May 2023
“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”