Margaret Huntley
13 Aug 2024 · Coroner Paul Appleton · Teesside and Hartlepool
The coroner's concerns
1. lack of understanding of steroid medication importance and response steps
“There is a lack of understanding amongst (non-clinical and clinical) Ambulance Service staff as to the importance of steroid medication and the steps to be taken should a patient (a) report that they are prescribed steroid medication and/or (b) present with symptoms potentially consistent with steroid insufficiency/Addison's Crisis”
2. absence of triage guidance for steroid medication during calls
“There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it; (b) actions to be taken or processes to follow should a patient”
3. uncertainty about Steroid Emergency Card issuance and usage
“It is unclear as to whether [the deceased] had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage, and awareness, of Steroid Emergency Cards”
4. inadequate GP awareness and routine use of alert system
“It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service's system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP's; (b) this action is not routinely being taken by GPs”