David Mason

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

12 June 2023 

Nicholas H Lane,  
HM Assistant Coroner for Worcestershire 

Dear Mr Lane 

DAVID ERNEST MASON (DECEASED) 

I am writing in response to the preventing future deaths report that was sent to our executive officer at the 
Association of Ambulance Chief Executives and I respond as our Managing Director on behalf of AACE. 

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh 
Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, 
co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the 
English ambulance services and the improvement of patient care. It is a company owned by NHS 
organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison 
Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not 
constituted to mandate or instruct ambulance services however it has national influence via the regular 
meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-
groups.  

Your first matter of concern relates to our ‘JRCALC guidance’ not being sufficiently clear that patients who 
may have suffered trauma or physiological stress also require steroid treatment, to prevent an adrenal 
crisis. The JRCALC guidelines have been in existence since the 1990’s but it was only in 2022 that we 
decided that a standalone guideline for steroid dependent patients was needed. We have decided that the 
wording and emphasis on administering steroids to patients who suffer trauma or physiological stress could 
have more emphasis placed on it, so we are now in the process of revising our guidance. We worked 
closely with members of the Addison’s disease self-help group and sought advice from The Addison’s 
Clinical Advisory Panel Chair 
guidance and are now re-engaged with them again to ensure our revised guidance is accurate and will also 
reflect advice that is given to patients.  

 in developing our current steroid dependent patients 

With regard to your second matter of concern about the advice given in ambulance control centres to 
people who call 999. Calls to 999 in the West Midlands region are assessed in accordance with the 
Department of Health National Guidelines using a process called NHS Pathways (NHSP) and therefore we 
have no responsibility for making changes to this system. We are aware from West Midlands ambulance 
service that the mater has been raised with NHSP. We are however aware of the development of an 
educational e learning package for call handlers so they have a better understanding and awareness of 
Addison’s disease and steroid dependent patients. The package will be trialled in Yorkshire and is being 
developed in conjunction with The Pituitary Foundation. Once the learning package has been evaluated as 
effective, we will aim to push this out to other ambulance services for them to consider using for their own 
control room staff.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 On behalf of AACE, I would like to extend our sincere condolences to the family of David Ernest Mason. 

If you have any further questions please do not hesitate to get in touch. 

Yours sincerely 

Managing Director

HM Assistant Coroner Nicholas H Lane 
Worcestershire Coroner’s Court  
The Civic 
Martin’s Way  
Stourport-on-Severn 
Worcestershire  
DY13 8UN 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

14 June 2023  

Dear Mr Lane, 

Re: Regulation 28 Report to Prevent Future Deaths – David Ernest Mason who 
died on 7 March 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 April 
2023 concerning the death of David Ernest Mason on 7 March 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to David’s family and loved ones. NHS England are keen to assure 
the  family  and  the  coroner  that  the  concerns  raised  about  David’s  care  have  been 
listened to and reflected upon. 

I address the two concerns addressed to NHS England within your report below.  

Concern  One:  That  certain  ambulance  call-handler  pathways  do  not  allow  for 
patients at risk of developing an adrenal crisis to be adequately considered by 
ambulance service control centres. 

NHS  Pathways  is  a  telephone  and  digital  triage  Clinical  Decision  Support  System 
(CDSS)  that  has  been  in  use  since  2005  within  the  Urgent  and  Emergency  care 
setting.  It  is  used  in  all  NHS  111  and  over  half  of  the  English  ambulance  services, 
including  West  Midlands  Ambulance  Service  University  NHS  Foundation  Trust 
(WMAS).  

The  safety  of  the  clinical  triage  process  endpoints  resulting  from  a  111  or  999 
assessment  using  NHS  Pathways  is  overseen  by  the  National  Clinical  Assurance 
Group, an independent intercollegiate group hosted by the Academy of Medical Royal 
Colleges (AoMRC). Alongside this independent oversight, NHS Pathways ensures its 
clinical content and assessment protocols are consistent with the latest advice from 
respected bodies that provide evidence and guidance for clinical practice in the UK. 
This includes latest guidelines from 

a.  NICE (National Institute for Health and Care Excellence).  
b.  The UK Resuscitation Council; and 
c.  The UK Sepsis Trust.  

The system is built around a clinical hierarchy, meaning that life-threatening symptoms 
are  assessed  at  the  start  of  the  call  triggering  ambulance  responses,  progressing 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 through to less urgent symptoms which require a less urgent response (or disposition) 
in other settings.  NHS Pathways is not diagnostic, but instead works on the basis of 
'ruling out'. This means that questions are asked in order to rule out possible reasons 
for the patient’s symptoms, until a point where it is safe for the patient to manage their 
own symptoms with advice or further intervention is needed by a clinician to establish 
a possible cause.  

The majority of calls taken using NHS Pathways are handled by a highly trained but 
non-clinical  Health  Advisor.  Health  Advisors  (as  per  the  NHS  Pathways  Provider 
Licence) should have access to support from clinicians to support safe call-handling. 
Even  though  thorough  training  is  provided,  it  is  not  within  the  remit  of  the  Health 
Advisor to be trained in, or understand more complex medical elements, such as in 
this case. Indeed, such enquiry can add confusion and delays to the management of 
the case and triaging process. It is for these reasons that questions on past medical 
history or pharmacology are utilised sparingly across the system, and only where it is 
deemed that a clear understanding can be sought. 

If a patient is unconscious the lowest disposition (outcome) they can reach would be 
a Category 2 emergency ambulance, and questions around adrenal insufficiency do 
not  present  because  it  will  not  impact  the  category  of  ambulance.  However,  after 
dispatch the system goes on to ask whether the caller has known adrenal insufficiency 
and, if so, offers specific in-line advice about administration of an emergency steroid 
kit.  

Patients with adrenal insufficiency, such as David, are often knowledgeable about their 
condition and have specific instructions from their specialist on when and how to use 
emergency  treatment  kits.  Injuries  are  common  in  the  general  population,  but  the 
prevalence of adrenal insufficiency across that population, whose triage assessment 
is supported by the NHS Pathways system, is relatively infrequent.  If a patient with 
adrenal insufficiency is conscious at the time of a call, the risk posed through extra 
questioning on complex themes is thought to outweigh the urgency of advice.  Adding 
enquiries about a topic where, (a) affected patients are likely to be aware of what to 
do and (b) such enquiries would delay the care or add confusion in the management 
of unaffected patients, has been considered and balanced in the design of this system 
and endorsed by the National Clinical Assurance Group. 

However, having learned of this case, NHS Pathways will engage with its stakeholders 
and  monitor  emerging  evidence  and  guidelines  with  respect  to  emergency  steroid 
replacement therapy in the pre-hospital setting, with a view to making system changes 
where appropriate in accordance with the governance framework. If it is established 
that  system-wide  changes  are  required,  NHS  Pathways  will  work  closely  with 
colleagues in the ambulance sector to ensure safety-netting advice is appropriate. 

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.  

Concern  Two:  It  was  not  clear  what  follow-up  action  is  being  taken  by  NHS 
England with regard to monitoring of compliance by NHS Trusts with National 
Patient  Safety  Alerts.  In  this  case,  alert  NatPSA/2020/005/NHSPS,  requiring 

 
 
 
 
 
 
 acute trusts to review admission/assessment/clerking documentation to ensure 
clinicians  are  prompted  to  check  whether  patients  suffer  from  adrenal 
insufficiency.  

NHS England has worked closely with the Society for Endocrinology and the Royal 
College  of  Physicians  on  the  issue  of  under-recognition  and  treatment  of  adrenal 
insufficiency  or  crisis.  This  culminated  in  the  publication  of  ‘Guidance  for  the 
prevention and emergency management of adult patients with adrenal insufficiency’ in 
July  2020,  which  outlines  the  causes  of  adrenal  insufficiency,  groups  at  risk  of  an 
adrenal crisis, emergency management and management for surgical procedures. As 
a result of work in this area, a new NHS Steroid Emergency Card was developed, to 
be  carried  by  patients  at  risk  of  adrenal  crisis  and  ensure  the  prompt  delivery  of 
steroids to those patients presenting within an emergency or acute medicine setting.   

The work above also resulted in the publication of the National Patient Safety Alert 
(NatPSA), mentioned in your report, which includes the specific action that ‘Providers 
that treat patients with acute physical illness or trauma, or who may require emergency 
or elective surgical or other invasive procedures, including day patients, should review 
their admission/assessment/examination/clerking documentation to ensure it includes 
prompts to check for risk of adrenal crisis and to establish if the patient has a Steroid 
Emergency Card.’ Trusts were expected to implement actions around this specific alert 
by 13 May 2021.  

Alert  compliance  data  for  NatPSAs  is  published  monthly  on  the  Central  Alerting 
System website. Guidance issued to NHS staff in August 2022, outlines the separate 
roles  and  responsibilities  of  the  national  Patient  Safety  Team,  the  region,  the 
Integrated Care Board (ICB) and the providers regarding issuing and complying with 
alerts. The national team at NHS England has statutory responsibilities for identifying 
new  or  under-recognised  issues  and  issuing  NatPSAs  when  required  but  are  not 
responsible for overseeing compliance. It is the role of ICBs to have local mechanisms 
in place to support compliance with any actions required in NatPSAs, in line with NHS 
Standard Contract requirements and the national Patient Safety Strategy. Regions and 
ICBs  are  expected  to  have  sight  of  providers  who  do  not  complete  actions  by  the 
required dates and provide support and assurance where this occurs.  

In this case, Worcestershire Acute Hospitals NHS Trust declared compliance in March 
2022. There are currently three Trusts who remain non-compliant. The national team 
at  NHS  England  has  asked  regional  colleagues  to  engage  with  the  relevant  ICBs 
regarding these Trusts. It is ultimately the role of the Care Quality Commission (CQC) 
to ensure the implementation of actions set out in alerts,  which is made clear in all 
NatPSAs, through the following statement; ‘Failure to take the actions required under 
this National Patient Safety Alert may lead to CQC taking regulatory action’. 

Other considerations  

NHS England has also engaged with the Association of Ambulance Chief Executives 
(AACE), on the concerns raised in your report. The AACE are responsible for the Joint 
Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice 
guidelines (JRCALC guidelines). The guidelines advise that ambulance services in the 
UK should carry hydrocortisone on their vehicles. The AACE had previously reviewed 

 
 
 
 
 
 
 what  process  each  UK  ambulance  service  had  in  place  regarding  adrenal 
insufficiency,  with  all  services  responding  that  paramedics  were  able  to  administer 
hydrocortisone  for  the  emergency  treatment  of  adrenal  insufficiency,  together  with 
most technicians/non-registered staff.  

Following our engagement with the AACE, we have been advised that there will be 
some amendments made to the JRCALC guidelines for steroid dependent patients, to 
help improve understanding of the need for administering steroids in cases of trauma. 
These amendments have already been drafted and will be published shortly.  

I would also like to provide further assurances on national NHS England work taking 
place around Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors, and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around preventable deaths are shared across the NHS at both a national 
and regional level and helps us pay close attention to any emerging trends that may 
require further review and action. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

NICE National Institute for 

Health and Care Excellence 

2nd  Floor 
2 Redman  Place 
London 
E20 1JQ 
United Kingdom 

+44 (0)300 323 0140 

Mr Nicholas Lane 
H M Assistant Coroner, Worcester Coroner Area 
The Civic 
Martins Way 
Stourport on Severn 
Worcestershire 
DY13 8UN 

Dear Mr Lane, 

Re: Regulation 28 Prevention of Future Deaths letter David Ernest Mason, deceased 

I write in  response to your regulation 28  report of 19 April 2023 regarding the very sad death 
of Mr David  Ernest Mason. I would like to express my sincere condolences to Mr Mason's 
family. 

We have reflected on the circumstances surrounding  Mr Mason's death, and the concerns 
raised in your report.  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. 

I can confirm that the scope of this guideline covers adrenal crisis including identification and 
emergency management and preventing adrenal crisis during periods of physiological 
stress, which includes trauma.  Membership of the guideline committee recruited for this 
topic includes two paramedic co-optees, as well as health professionals who see people with 
adrenal crisis or who are at risk of adrenal crisis in the emergency department. 

Please do let me know if you require any further information and again,  I offer my sincerest 
condolences to Mr Mason's family. 

Yours sincerely, 

Chief Executive 

NICE 

www.nice.org.uk I nice@nice.org.uk

To Whom it May Concern, 

Thank you for forwarding us this information. We are so sorry to hear of the death of Mr David Mason, and 
collectively would like to offer condolences to his family.  

We note the circumstances described in the report. 

Information available currently states the need for additional hydrocortisone in adrenal insufficiency for 
trauma and physiological stress https://www.rcpjournals.org/content/clinmedicine/17/3/258 .  

All NHS health care providers have been sent the National Patient Safety Alert with gives as an example the 
death of a patient with a hip fracture, and point 3 states the need to give additional steroids for acute 
physical illness or trauma https://www.england.nhs.uk/publication/national-patient-safety-alert-steroid-
emergency-card-to-support-early-recognition-and-treatment-of-adrenal-crisis-in-adults/. We would 
strongly 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.  

Trauma and physiological stress are within scope for the NICE guideline on adrenal insufficiency currently 
in development. There is representation from paramedics, Emergency Medicine, General Practice and lay 
members on the committee so the guidelines will cover pre hospital care. Once guidelines are published 
there is a plan for another round of communications to disseminate the information.  

The Society for Endocrinology will have opportunity to review this when it is shared with stakeholders and 
provide comments. Also, members of the Society for Endocrinology are on the committee writing the 
guidelines and will ensure these topics are covered. In terms of Ambulance service, JRCALC has protocols 
advising on the management of patients with adrenal insufficiency. 
present and we will ensure all protocols align and are clear about the need to give additional oral or IM 
hydrocortisone in trauma/injury.  JRCALC guidelines state anyone can give IM hydrocortisone and we are 
aware that there is an issue around paramedics and technicians being reminded both groups can 
administer emergency treatment. This is important as different types of ambulance have different health 
care professionals working on them. 

 is liaising with them, at 

In terms of the NHSE steroid emergency card, the wording states injury/shock. We will continue our work 
with both ambulance services and 999/111 services via NHSE patient safety team to ensure this is on the 
triage information to call handlers so a category 2 ambulance can be sent. All ambulances carry 
hydrocortisone, and both paramedics and ambulance technicians are able to administer IM hydrocortisone 
so this should not be a blocker to administration. JRCALC may be able to address this in their guidelines. It 
is possible thatmore work is needed to disseminate the information available and we can continue working 
with RCP Patient Safety Committee and NHSE Patient Safety team in this regard. We will also update our 
resources accordingly.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 In order to support health and care providers, the Society for Endocrinology has set up a webpage with 
resources to help health care teams develop resources to support management of adrenal sufficiency.  We 
will review this once NICE guidelines are written and ensure that pre-hospital care is covered more clearly. 
We would be happy to work with Worcestershire Acute Hospitals NHS Trust to review their materials if 
helpful.   

https://www.endocrinology.org/adrenal-crisis  

We are aware that, in the current climate with pressures on ambulance services and emergency 
departments, there may be delays in patients with adrenal insufficiency being managed appropriately. We 
will continue to liaise with the NHSE patient safety team and Royal College of Emergency Medicine to 
ensure that patients with adrenal insufficiency are given additional hydrocortisone in the appropriate way 
to prevent further deaths.   

Please let us know if you require any further information or clarification. 

, Consultant Endocrinologist, Chair of Clinical Committee 

 Consultant Endocrinologist, RCP Patient Safety Committee, Medicines Safety Joint 

Working Group, NICE Topic Advisor adrenal Insufficiency Guideline 
, Consultant Endocrinologist, GIRFT Lead 

On Behalf of the Clinical Committee of the Society for Endocrinology

Mr Lane 
HM Assistant Coroner for Worcestershire 
The Civic 
Martins Way 
Stourport on Seven 
DY13 8UN 

1 June 2023 

Dear Mr Lane 

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  –  David  Ernest  Mason 
(Deceased) 

Thank you for your email dated 20 April 2023 attaching your Regulation 28 Report. 

Firstly, I am sorry that you have had to raise concerns with West Midlands Ambulance 
Service University NHS Foundation Trust (WMAS) following the inquest of Mr Mason. 
Can I please take this opportunirty to pass on my sincere condolences to the family of 
Mr Mason. 

Please see our response to your concerns. 

Concern 1 
Evidence heard at the inquest demonstrated that no clinician involved in providing pre-
hospital care to Mr Mason 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  Mason 
required  additional  replacement  steroid  therapy,  to  prevent  the  development  of  an 
acute adrenal crisis. 

Response 
In 2017 there was an update in the Joint Royal Colleges Ambulance Liaison Committee 
(JRCALC) guidance emphasising the increased usage of Hydrocortisone for patients 
with  adrenal  crisis, 
in  doubt  administer 
Hydrocortisone. This was communicated to all staff  through the clinical times edition 
30. The clinical times is an internal quarterly breifing which provides all staff with new 
or updated clinical guidance. 

further  note  stating 

including  a 

if 

In September 2020 under the medical emergencies section of JRCALC was updated 
to highlight that a joint National Patient Safety Alert was issued by NHS Improvement 
and NHS  England about  Steroid  Emergency  Cards to  support  early  recognition  and 
treatment of adrenal crisis in adults. Small amendments were made in the guidelines 
to highlight the need to be alert for a patient having an emergency card for a specific 
condition.  For  example  a  steroid  emergency  card  or  an  alert  card  for  a  patient  with 
COPD  regarding  oxygen  therapy.  This  was  highlighted  to  all  staff  through  clinical 
notice 431. 

 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 In  February  2022  JRCALC  issued  a  new guideline  titled steroid  dependant  patients, 
this guideline was highlighted to all staff through clinical notice 484. This also included 
permitting WMAS ambulance technicians to administer hydrocortisone IM to patients 
as well as Paramedics. 

All  WMAS  clinicians  are  given  access  to  the  JRCALC  guidelines  through  individual 
licenses for the JRCALC Plus app. Staff are also provided a Trust personal issue Ipad 
and the app can be accessed through this device, or there is the option for the app to 
be also downloaded on other devices such as personal smart phones if they so choose 
so. This allows clinicians to access the guidelines whilst at the patient side. 

As  well  as  the  above  a  number  of  articles  have  been  run  within  the  WMAS  weekly 
briefing. The weekly breifing which is emailed to all WMAS employees provides all the 
latest information about WMAS and any changes to guidance that have been made by 
external bodies in relation to clinical practice that must be considered. An example of 
such is below: 

Steroid Emergency Card 
All clinicians are to be aware of recently published national guidance that promotes a 
new  patient-held  Steroid  Emergency  Card.  The  guidance  and  card  are  designed  to 
help  healthcare  staff  identify  adrenal  crisis  in  adults  and  gives  information  on  the 
emergency treatment to start if the patient is acutely ill, or experience trauma, surgery 
or other major stressors. For further information please go to: 
www.rcpjournals.org/content/clinmedicine/20/4/371 
www.endocrinology.org/ 
www.pituitary.org.uk/ 
www.addisonsdisease.org.uk/ 
www.jrcalc.org.uk/guidelines/ 

Concern 2 
Evidence heard at the inquest demonstrated that when information is given to an EOC 
(emergency operations centre) call-handler at WMAS that a patient has a diagnosis of 
Addison’s disease and has suffered trauma, the call-handler question pathway (which, 
the inquest heard, is based on a computer-programmed logarithm (designed by NHS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Digital,  now  part  of  NHS  England))  does  not  go  on  to  consider  the  risk  of  adrenal 
insufficiency  and  the  requirement  for  replacement  steroid  therapy  to  commence 
immediately.  This appears to be potentially relevant both in respect of whether time-
critical steroid treatment may be required (and thus for a holistic consideration of call 
categorisation) and safety-netting advice that should be given (for additional doses of 
steroid medication to be taken by the patient, prior to any ambulance arrival).  Safety-
netting  advice  takes  on  even  greater  significance  in  the  current  climate,  where 
healthcare  demand  and  pressures  on  capacity  are  often  causing  severe  delays  in 
ambulance attendance.  Evidence heard at the inquest confirmed that the position is 
different  if  information  is  given  that  the  patient  is  medically  unwell,  particularly  if 
concerns  of  a  cardiac  nature  are  present  or  adrenal  insufficiency  may  be  the  direct 
cause  of  current  illness,  with  the  call-handler  question  pathway  then  going  on  to 
consider the risk of adrenal insufficiency.  Currently there is a cohort of patients (which 
included Mr Mason) whose risk of developing an adrenal crisis is not being considered 
by call-handlers at WMAS. 

Response 
Calls  to  999  are  assessed  in  accordance  with  the  Department  of  Health  National 
Guidelines using a process called NHS Pathways (NHSP). 

NHSP is a patient assessment triage tool used to determine the most suitable level of 
care,  appropriate  to  the  presenting  symptoms  of  the  telephone  call.  It  is  a  national 
requirement to use an assessment system to triage all 999 calls, to assist Ambulance 
Services in prioritising the high number of calls received. WMAS are unable to make 
changes to the system. 

WMAS Integrated  Emergency  Urgent  Care Clinical  Commander  who is the  Lead for 
NHS Pathways (NHSP) has raised the above as a clinical concern on the NHSP log. 
WMAS are awaiting a response from Pathways. 

Concern 3 
The  Serious  Incident  investigation  report  disclosed  by  WMAS  did  not  make  any 
recommendations in respect of improving clinicians’ knowledge of adrenal insufficiency 
and the importance of considering administering replacement steroid therapy. 

Response 
Following  review of the serious incident investigation and receipt of the PFD we agree 
a recommendation should have been made to raise awareness  and improve clinicians 
knowledge of adrenal insufficiency and the importance of considering adminsertering 
replacement steroid therapy. Therefore we have reemphasised the care of the steroid 
dependant patient with an in depth article with appropriate links for further reading and 
education, publishing the below in the clinical times on the 12th  of May 2023. 

Steroid Dependant Patients - Jason Wiles, Consultant Paramedic for Emergency 
Care 
Following  a  recent  coronial  inquest,  the  Trust  received  a  Regulation  28  Report  to 
Prevent  Future  Deaths  in  relation  to  clinicians’  knowledge  adrenal  insufficiency  and 
the  importance of  considering  administering  replacement  steroid  therapy particularly 
in the patient who has suffered the trauma of a fall, long lie and a fractured hip. In this 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
   
 
 
 
 
 case  the  patient  required  additional  replacement  steroid  therapy,  to  prevent  the 
development of an acute adrenal crisis. 
JRCALC provide guidance on the assessment and management of Steroid- dependent 
patient which are available to all clinicians through the JRCALC+ app. 

Incidence 

  Primary  Adrenal  insufficiency  (when  the  adrenal  glands  cannot  produce 
cortisol) affects 1 in 20,000 people in western Europe  affecting around 3,400 
people in the UK. 

  Secondary  Adrenal  insufficiency  (when  the  pituitary  gland  cannot  produce 
ACTH, and therefore cannot stimulate the adrenal gland to produce cortisol) is 
more common with 150 – 280 people per million affected. It is more common 
in women than men. The peak age of onset is between 50 and 60 years. 

Pathophysiology 
Glucocorticoid Steroid Dependant Patients 
The  cause  of  steroid  dependency  can  be  broken  down  into  three  types:  primary, 
secondary, and tertiary. 

1.  Primary adrenal insufficiency occurs in patients who have direct impairment of 
the  adrenal  glands  such  as  those  with  Addison’s  disease  (autoimmune 
endocrine  condition  where  the  adrenal  glands  cease  to  function),  congenital 
adrenal  hyperplasia  (genetic  condition)  or  surgery  or  trauma  to  the  adrenal 
glands. 

2.  Secondary  adrenal insufficiency  is caused  by  pituitary  disease,  hypothalamic 
or  pituitary  tumours  and  their  treatment  (surgery  and  radiotherapy)  or  brain 
injury. 

3.  Tertiary adrenal insufficiency may occur in patients who have taken steroids for 
prolonged periods of time, high doses, multiple courses, or via multiple routes.. 
Prolonged  use  may  lead  to  a  reduction  or  cessation  of  naturally  occurring 
cortisol production by the adrenal glands. 

Regardless of type, those with adrenal insufficiency are at risk of adrenal crisis which 
can be life threatening. 

Adrenal Crisis 
Adrenal crisis, also termed acute adrenal insufficiency, is a life-threatening endocrine 
emergency due to a lack of production of the adrenal hormone cortisol. 
Adrenal crisis can also occur if existing cortisol replacement does not meet the body’s 
increased need for cortisol due to illness such as fever, persistent vomiting or diarrhoea 
or trauma. Equally, sudden cessation of corticosteroid medication for conditions listed 
above, will risk adrenal crisis in those with adrenal insufficiency. 
Identifying patients at risk and prompt management can save lives. 
National  guidance  promotes  a  new  patient-held  Steroid  Emergency  Card  to  help 
healthcare staff identify patients with adrenal insufficiency and provide information on 
emergency treatment if the patient is acutely ill, experiences trauma, surgery or other 
major stressors. 
https://www.england.nhs.uk/publication/national-patient-safety-alert-steroid-
emergency-card-to-support-early-recognition-and-treatment-of-adrenal-crisis-in-
adults/ 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
   
 
 Assessment and Management 
Assessment  and  management  of:  Steroid  Dependant  Patients  or  at  risk  of  adrenal 
insufficiency 
Assessment 

  Assess <C>ABCD  MANAGEMENT 
 
  Major <C>ABCD problems, refer to Medical Emergencies in Adults – Overview 

If any of the following TIME CRITICAL features present: 

and Medical Emergencies in Children – Overview 

  Start correcting <C>ABCD problems. 
  Undertake a TIME CRITICAL transfer to nearest receiving hospital. 
  Continue patient management en-route. 
  Provide an ATMIST information call. 

Symptoms and signs of adrenal insufficiency include: 

  Severe fatigue, lethargy, drowsiness, confusion, coma 
  Low  blood  pressure,  postural  dizziness  and  hypotension  (≥20 mmHg  drop  in 
BP  from  supine  to  standing  position),  dizziness,  collapse,  in  severe  cases 
hypovolaemic shock 

  Abdominal  pain,  tenderness  and  guarding,  anorexia,  nausea,  vomiting  (in 

particular in primary adrenal insufficiency), diarrhoea 

  Fever 
  Patients  may  have  a  history  of  weight  loss  and  increasing  skin  pigmentation 

over weeks to months (primary adrenal insufficiency) 

  Assess patient for underlying acute conditions that may have precipitated the 

adrenal crisis and treat that condition too. 

Follow  Medical  Emergencies  in  Adults  –  Overview  and  Medical  Emergencies  in 
Children – Overview in addition to the specific management detailed below. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
   
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
  
 
 
 
 
  
 
   
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
   Measure and record pulse rate. 
  Measure and record respiratory rate. 
  Measure oxygen saturations 
  Measure and record blood glucose for hypoglycaemia. 
  Treat hypoglycaemia. Refer to Glycaemic Emergencies in Adults and Children. 
  Measure and record temperature. 
  These observations along with a blood pressure will enable you to calculate a 

 

NEWS2 Score, refer to Sepsis. 
If required, monitor and record 12-Lead ECG. Assess for abnormality, refer to 
Cardiac Rhythm Disturbance. 

  Measure  and  record  blood  pressure,  if  required  administer  fluids,  refer  to 
Intravascular  Fluid  Therapy  in  Adults  and  Intravascular  Fluid  Therapy  in 
Children. 

  Patients with adrenal crisis may be hypotensive or have postural hypotension. 

Assess for postural hypotension if normotensive when lying / sitting. 

  There may be a profound postural drop in blood pressure when the patient is 
moved from the lying position to semi-recumbent or sitting position. It may be 
necessary  to  give  IV  fluids  prior  to  moving  the  patient  if  extrication  requires 
head up posture. 

Administer Hydrocortisone Administer hydrocortisone to: 

  Patients  in  an  established  adrenal  crisis  (IV  or  IM  administration).  Ensure 

parenteral hydrocortisone is given prior to transportation. 

  Patients  with suspected  adrenal  insufficiency  or on  long-term  steroid therapy 
who  have  become  unwell  or  experience  trauma  to  prevent  them  having  an 
adrenal crisis. IM administration is usually sufficient. 
If in doubt about adrenal insufficiency hydrocortisone should be administered. 
 
  Pregnant  women  who have  Addison’s  disease who  are established  in  labour 

(regular painful contractions) should receive Hydrocortisone. 

  Refer to Hydrocortisone drug guideline. 

Conveyance to hospital 

  Convey  patients  who  have  required  intravenous  fluids  or  management  of 

hypoglycaemia. 

  Convey  patients  if  the  underlying  condition  precipitating  the  adrenal  crisis 

needs hospital assessment / management. 

Consider management in the community or referral to other services for: 

  Patients with mild illness / injury where they have followed their treatment plan 

to increase steroid dose and have normal physiological parameters. 

Appropriate advice 

  Patients on replacement steroids (e.g., Addison’s disease/hypopituitarism) may 
have  a  treatment  plan  to  increase  their  maintenance  steroids  in  the  event  of 
illness  /  injury.  This  should  be  followed  but  they  may  require  monitoring  and 
higher doses for more significant illness / injury. 

Key points 

  Adrenal  Crisis  is  a  Medical  Emergency  requiring  prompt  treatment  with 

Hydrocortisone and IV fluids. 

  Steroid  Dependant  Patients  can  have  an  Adrenal  Crisis  triggered  when  the 
body’s  requirement  for  corticosteroids  increases  such  as  due  to  infection  or 
trauma as the body is unable to increase its own production. 
If  extrication  requires  a  head  up  posture,  IV  fluids  may  be  required  before 
moving the patient to prevent profound postural hypotension. 

 

  Look  for  an  underlying  cause  that  may  have  triggered  the  episode  and  treat 

that condition too. 

Further reading 
https://bnf.nice.org.uk/treatment-summaries/adrenal-insufficiency/#management-of-
adrenal-crisis 
https://www.addisonsdisease.org.uk/emergency 
https://www.pituitary.org.uk/information/adrenal-insufficiency/ 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
   
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 
 
        
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
   
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
   
   
   
 Joint Royal Colleges Ambulance Liaison Committee, Association of Ambulance Chief 
Executives.  Steroid-dependant  Patients.  JRCALC  Clinical  Guidelines  2022:  Class 
Professional Publishing 2022. 

Concern 4 
Evidence heard at the inquest confirmed that the investigation lead at WMAS had not 
been  shown  the  inquest  disclosure  bundle,  which  had  been  disclosed  to  the  legal 
department at WMAS a number of months prior to the inquest.  This bundle contained 
relevant  evidence  from  a  different  internal  investigation  (by  WAHT),  suggesting  that 
the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and 
not,  as  had  been  considered  when  a  coronial  referral  had  initially  been  made, 
hyperkalaemia and rhabdomyolysis (following a fall and long lie).  This lack of internal 
co-ordination within WMAS prevented full internal investigation and learning in respect 
of  the  care  given  to  Mr  Mason  by  WMAS.  The  legal  department  of  WMAS  did  not 
attend the inquest (it was their right not to) nor were WMAS legally represented by an 
external  solicitor  or  barrister  (it  was  their  right  not  to  be).  Greater  engagement  and 
participation  in  the  coronial  investigation  and  inquest  process  would  improve  the 
Trust’s ability to learn from patient-safety incidents and enable the legal, governance 
and safety departments to better co-ordinate such investigations. 

Response 
Due to new staff starting within within the WMAS Coroners team, sending the bundle 
to  the  Lead  investigator  was  missed  on  this  occasion.  Please  accept  our  sincere 
apologise for this error in administration. 

The legal team at WMAS aim to attend as many inquests a possible. However, due to 
the increasing number of inquests throughout the West Midlands it is not possible to 
attend all inquests. 

May I once again please  pass on my sincere condolences to the family of Mr Mason. 

I  hope  this  response  provides  you  and  the  family  with  the  appropriate  level  of 
assurance  that  as  a  Trust  we  have  dealt  with  the  concerns  highlighted  within  your 
report. 

If you require any further assistance, please do not hesitate contact me. 

Yours sincerely 

Chief Executive Officer

Office of the Chief Executive Officer 

12 June 2023 

Mr N H Lane 
HM Assistant Coroner 
Worcestershire Coroners Court 
The Civic 
Martin’s Way 
Stourport on Severn 
Worcestershire 

Dear Mr Lane 

Re Regulation 28 Report to Prevent Future Deaths 

Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths sent on 19th 
April 2023, following the Inquest touching on the death of Mr David Mason.  

In your Regulation 28 report you identified the following matters of concern relating to the Worcestershire 
Acute Hospitals NHS Trust (WAHT)  

1) Evidence  heard  at  the  inquest  demonstrated  that  no  clinician  involved  in  providing  care  to  Mr
Mason (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  Mason  required  additional  replacement  steroid  therapy,  to  prevent  the
development of an acute adrenal crisis.

2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal
insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-
based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are
on the same page as advice to patients and families for long-term condition management) does
not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency
who have suffered trauma or physiological stress.

3) Evidence  heard  at the  inquest (relating to the trauma/surgical  department  at WAHT)  suggested
that  it  is  likely  that  many  clinicians  (including  at  consultant  level)  do  not  have  a  well-developed
understanding of adrenal insufficiency and the crucial importance of administering replacement

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD 

 
   
 
 
 
 
 
 Office of the Chief Executive Officer  

steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering 
an adrenal crisis. 

4)  Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking 
documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency.  
Although the inquest was informed that changes have been made in this regard by WAHT to some 
peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) 
requires  acute  trusts  to  review  admission/assessment/clerking  documentation  to  ensure  such 
prompts are included. 

Responding to the concerns raised; 

1.  In order to raise awareness and educate clinicians, the following actions have been taken. 
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 of adrenal insufficiency for T&O Junior Doctors 
delivered by a consultant Anaesthetist is now given three times per year as part of the induction 
programme (appendix 4). A Lesson of the Week has been shared on 25th May 2023 (appendix 
5), with Governance teams to disseminating it through Divisions, in the Trust “Worcestershire 
Weekly”, Datix Incident management system and the Trust Intranet page. 

2.  The Trust guideline, based on National guidance, has been amended to include clear advice for 
all patients in the Emergency Departments who require admission (appendix 6). Following 
discussion with our Endocrinology and Emergency Department teams, it was felt that this would 
be the most effective way of ensuring that clinicians were aware of the need for additional steroid 
replacement therapy for patients at risk of adrenal crisis due to physiological stress and pain. 

3.  Covered in point 1 above. 

4.  Changes have been made to the ED admission documents, implemented 6th June 2023, to 

include prompts on time critical medications, including steroids, and to consider increasing the 
dose of steroids (appendix 7). The T&O admission document, as discussed at the Inquest, was 
updated in October 2022 to include Steroid Management prompts (appendix 8). 

I  hope  that  the  above  addresses  your  concerns  about  the  quality  of  our  initial  review.    I  have  no 
representations in respect of publication of the Regulation 28 or this response by the Chief Coroner. 

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD 

 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 Office of the Chief Executive Officer  

I shall be grateful if you could kindly send a copy of my response to anyone to whom you copied your 
Regulation 28 report.  

Yours sincerely                   

Chief Executive  

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD