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recurance

Terence Bradfield

11 Mar 2019 · Coroner Deborah Archer · Plymouth Torbay and South Devon

The coroner's concerns

  1. 1. steroid administration

    “Mr. [name redacted] was not given his steroids on 2.12.13”
  2. 2. intravenous hydrocortisone prescription

    “Mr. [name redacted] was not prescribed intravenous hydrocortisone on 4”
  3. 3. stress dose steroid administration

    “Mr. [name redacted] was not put on a stress dose of steroids whilst in Derriford hospital”
  4. 4. staff awareness and training

    “The awareness and training of staff on the issue of steroid management”
  5. 5. absence of steroid administration policy

    “The lack of a policy on the administration of steroids generally and their use in situations where a number of co - morbidities are present”
  6. 6. staff awareness of Nil by Mouth

    “The training and awareness of staff on the meaning of * Nil by Mouth”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Terence Bradfield · Recurance