Margaret Huntley

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

E:

T:  020 7118 0977

W: www.aace.org.uk

30 September 2024

BY EMAIL:  

Paul Appleton
Assistant Coroner for Teesside and Hartlepool Coroner's
Service

Dear Mr Appleton

MARGARET HUNTLEY (DECEASED)

I am writing in response to the preventing future deaths report received at the Association of Ambulance
Chief Executives and I respond as our Director of Operational Development and Quality Improvement on
behalf of AACE.

On behalf of AACE, I would like to extend our sincere condolences to the family of Margaret Huntley.

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh NHS
ambulance services. Its purpose is to support its members, UK NHS ambulance services, in the
implementation of national agreed policy and to act as an interface, where appropriate at a national level,
between them and their stakeholders. It is a company owned by NHS organisations and possesses 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 chairs along with a network of national specialist sub-groups.

We respond in relation to your matters of concern:

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.

Firstly, it is important to note that the education and training of paramedics is not within the remit of AACE
or JRCALC.

Secondly,  JRCALC guidelines are advisory and have been developed to assist healthcare professionals
inform patients and to make decisions about the management of the patient’s health, including treatments.
This advice is intended to support the decision-making process and is not a substitute for sound clinical
judgement. The guidelines cannot always contain all the information necessary for determining appropriate
care and cannot address all individual situations; therefore, individuals using these guidelines must
personally ensure they have the appropriate knowledge and skills to enable suitable interpretation. All our
JRCALC guidance is updated on a regular basis. The guidance is available to all UK ambulance
paramedics and is used on an App.

The JRCALC guidelines contain a specific guideline called ‘Steroid-dependent patients’. This guideline
details the assessment and management of patients that are dependent on steroids. We also have
separate guidance around the indications for administering hydrocortisone which we know is carried on all
ambulances.

 We are engaging with the Addison’s Disease Self-Help Group and the Pituitary Foundation so that they
can provide information to patients with regard to ensuring their health care record contains information
that they are steroid-dependent and explaining how people can be reassured about what happens and
what can be done to ensure if emergency help is needed, such as a 999 ambulance, that they receive the
best care possible.

In relation to the second matter of concern:

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 raise during a
call that they are prescribed steroid medication.

AACE are not responsible for the guidance or processes for ambulance staff triaging calls. NHS
Ambulance Services are required to process 999 calls through an approved triage system and there are
currently two different systems in use in ambulance trusts. We know that these systems are able to advise
patients to take their emergency supply of steroids.

In relation to the third matter of concern:

It is unclear as to whether Margaret Huntley 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.

Within our JRCALC guidance for steroid-dependent patients, we have an image of the NHS steroid
emergency card. We included this particularly to help raise awareness amongst ambulance clinicians.
In addition ambulance clinicians can often gain access to the patients’ health care record where clinical
information such as steroid dependency may be available.

In relation to the final matter of concern:

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.

AACE do not support routine ‘flagging’ of patient addresses for steroid-dependent patients.  We know that
the majority of ambulance services have moved or are moving away from this due to a number of
governance and risk issues. One example of an issue is that if a flag is placed against a patients address,
the patient may have moved house or died, therefore, the validity of the flag becomes flawed. Or, if the 999
call is made from somewhere other than the flagged address, the flag is then not useful. We do however
support important information being documented on the patients summary care record or care plan.

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

Yours sincerely

Director of Operational Development and Quality Improvement

Strictly Private and Confidential  
Mr Paul Appleton 
Assistant Coroner 
His Majesty's Coroner for Teesside and Hartlepool  
The Coroner's Service 
Middlesbrough Town Hall 
Albert Road 
Middlesbrough 
TS1 2QJ 

Date: 23rd October 2024 

Dear Mr Appleton, 

Inquest into the death of Margaret Huntley 

Regulation 28 – Report to prevent future deaths  

Ambulance Headquarters 
Bernicia House 
The Waterfront 
Goldcrest Way 
Newburn Riverside 
Newcastle upon Tyne 
NE15 8NY 

Tel: 

www.neas.nhs.uk 

Ref: 

I  am  writing  in  my  role  as  Chief  Executive  of  North  East  Ambulance  Service  NHS 
Foundation Trust ("NEAS") in response to the Regulation 28 report for the prevention 
of future deaths dated 13th August 2024 as issued by you following the inquest into 
the tragic death of Margaret Huntley. I am sorry that you have had to raise concerns 
with  NEAS  following  the  inquest  and  would  like  to  take  this opportunity  to pass  my 
sincere condolences to the family of Margaret. 

I am aware that the report was also issued to NHS England, Association of Ambulance 
Chief Executives and Royal College of General Practitioners. My team have liaised 
with  colleagues  within  Association  of  Ambulance  Chief  Executives  in  drafting  our 
response to ensure a consistent response from the ambulance sector. 

The matters of concern listed in your report are: - 

1.  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.  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, f 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 raise during a call that they are prescribed 
steroid medication. 

 
 
 
 
 
 
 
 
 
 
 
 3.  It  is unclear as  to  whether Margaret  Huntley 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.  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. 

I will address each point you have raised in your matters of concern below: - 

1.  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 
steroid 
potentially 
symptoms 
insufficiency/Addison’s Crisis. 

consistent 

with 

with 

In respect to emergency ambulance clinicians (Paramedics), it may be helpful 
to explain the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) 
guidance before I answer this specific concern. The JRCALC guidelines have 
evolved  from  many  locally  derived  protocols  to  systematically  developed 
national  clinical  practice  guidelines  based  on  current  best  evidence.  The 
ongoing  continuous  updates  are  supported  via  the  JRCALC  Guideline 
Development Group (JRCALC-GDG), led by Dr Simon Brown, have over the 
years  been  responsible  for  developing  and  reviewing  the  national  clinical 
practice  guidelines  for  NHS  Paramedics.  JRCALC  guidelines  are  also  an 
important part of clinical risk management and ensure uniformity in the delivery 
of  high-quality  patient  care.  As  such,  they  form  the  basis  for  UK  Paramedic 
training  and  education.  JRCALC  combines  expert  advice  with  practical 
guidance to  help  Paramedics  in  their  challenging  roles  and  supports  them  in 
providing patient care. The guidelines cover an extensive range of topics, from 
resuscitation, medical emergencies, trauma, obstetrics and medicines to major 
incidents and staff wellbeing. 

The guidelines  are  now  reviewed  and updated  on  a rolling basis.  Due  to  the 
rapidly developing evidence base and the emerging technological options for 
publication,  the  guidelines  are  developed,  updated  and  made  available  in  a 
variety of format options. Working closely with the National Ambulance Service 
Medical Directors (NASMeD), guideline development sub-groups will develop 
specific  guidelines  that  conform  to  the  AGREE  II  standard  which  can  be 
accessed 
https://www.jrcalc.org.uk/wp-
content/uploads/2014/12/JRCALC-process.pdf. I have also enclosed a copy of 
the JRCALC Standard for Guideline Development. 

following 

link 

the 

via 

In  2017  there  was  an  update  in  the  Joint  Royal Colleges  Ambulance  Liaison 
increased  usage  of 
Committee  (JRCALC)  guidance  emphasising 
Hydrocortisone for patients with adrenal crisis, including a further note stating 
if in doubt administer Hydrocortisone.  

the 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Qual ity Commission (Provider ID: RX601).  

 
 
 
 
 
 In September 2020 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. I have enclosed a copy of the alert 
which was issued.  

In  February  2022  JRCALC  issued  a  new  guideline  titled  steroid  dependant 
patients,  that  provided  greater  information  on  the  different  classifications  of 
adrenal insufficiency.   

All  NEAS  clinicians  are  given  access  to  the  JRCALC  guidelines  through 
individual licenses  for  the  JRCALC Plus  app.  JRCALC Plus  allows individual 
ambulance  services  to  combine  the  national  guidelines  with  their  regional 
information, this is achieved via individual login details linking with the specific 
Ambulance Trust. The app contains the following which is utilised by NEAS: 

▪  Complete JRCALC Guidelines; 
▪  Regional and local guidance specific to NEAS 
▪  Clinical Notices/Bulletins  
▪  Medications information including patient group directives.   
▪  All  updates  and  alerts  are  published  in  real  time  as  new  guidance  is 

issued; 

▪  The app works offline and is therefore accessible to our teams. 

Emergency  Ambulance  crews  can  access  the  JRCALC  Plus  app  via  iPads 
which are now being transitioned to   personal issue, with the rollout of personal 
issue  devices  commencing  in  August  2024,  prior  to  this  date  the  iPad  (or 
previous  electronic  device)  was  part  of  the  standard  vehicle  equipment.  In 
addition, the clinicians have the option for the App to be 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  and/or  when 
travelling to the case. 

As  well  as  the  above  several  articles  and  education  package  have  been 
developed and delivered within the NEAS.  These include 2 clinical alerts, which 
are  the  primary  way  NEAS  cascades  information  to  its operational teams  on 
matters of clinical practice:  

▪  Medical Directorate alert – Steroid Dependent Patients - issued on the 

▪  Clinical Directorate alert – Adrenal Insufficient Patients – Issued on the 

7th August 2023 

30th July 2024 

I have enclosed copies of both the alerts detailed above. 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Qual ity Commission (Provider ID: RX601).  

 
 
 
 
 
 
 
 
 
 
 
 NEAS  will,  as  part  of  the  learning  from  this  tragic  event,  provide  more 
educational opportunities for its staff including the following: 

▪  Sharing the details of this training event: 

https://www.addisonsdisease.org.uk/adshg-paramedic-training-in-
adrenal-crisis-management 

▪  Sharing some more resources on adrenal insufficiency and steroid 
dependency through our corporate communications channels. 
▪  We have commenced the development of a training module on time 
critical medications (which will include Steroids) in our Statutory and 
Mandatory Training module.  This will be included in the Statutory and 
Mandatory training delivered in 2025/2026. 

Upon  liaising  with  colleagues  within  the  Association  of  Ambulance  Chief 
Executives (AACE). I am aware that  AACE colleagues are engaging with the 
Addison’s  Disease  Self-Help  Group  and  the  Pituitary  Foundation.  This  joint 
work is to help ensure that they can provide information to patients in regard to 
ensuring  their  health  care  record  contains  information  that  they  are  steroid 
dependent.  In  addition.  explaining  how people  can  be  reassured  about  what 
happens and what can be done to ensure if emergency help is needed such as 
a 999 ambulance that they receive the best care possible. 

Turning towards non-clinical colleagues, specifically Health Advisors, working 
within  the  Emergency  Operations  Centre  (EOC)  using  the  NHS  Pathways 
system,  currently  version  45.2.0.    The  NHS  Pathways  system  is  a  national 
system and has been designed to be used by non-clinicians who ask a series 
of  evidence-based  questions  to  reach  an  end  point.  That  end  point  is  not  a 
diagnosis, it is just what care and in what timeframe the care is needed. This is 
then matched to the most appropriate local services who deliver that care. NHS 
Pathways is not a diagnostic tool, 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.  

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. This is further complicated due to the vast range of medication which 
patients  may  be  prescribed  or  purchase  over  the  counter,  including  highly 
specialised medication. 

Due to the fact NHS Pathways is a national system, it is not possible for NEAS 
to implement a process where Health Advisors will ask the caller to share the 
details/names of medication, which in turn would need to input as notes for the 
attending  ambulance  crew.  Based  on  the  rationale  above,  the  vast  range  of 
medication  would  lead  onto  errors  in  recording  the  name  of  medication  and 
pose additional risks.   

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Qual ity Commission (Provider ID: RX601).  

 
 
 
 
 
 The current version of NHS Pathways does include supporting information for 
Health Advisors, in respect to adrenal insufficiency, however we do recognise 
that  Health  Advisors  may  benefit  from  further  information  about  Addisons 
disease and specifically adrenal crisis. We are therefore in the process of rolling 
out  a  refresher  training  bulletin  confirming  the  steps  to  take  in  these 
circumstances with some further information relating to the condition. This will 
be monitored to ensure it has been read and understood by all Health Advisors 
and those who receive calls via the 111 and/or 999 services. Linking with my 
response  to  your  second  concern,  we  will  support  any  changes  made  in  the 
NHS  Pathways  system  alongside  any  requirements  to  provide  additional 
information, instruction or training to our call handling teams. 

2.  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 raise during a call that they are prescribed 
steroid medication. 

The computer programme and algorithm used by NEAS, and other ambulance 
services  across  the  country,  is  the  NHS  Pathways  telephone  triage  system 
which  is  a  clinical  decision  support  system  (CDSS)  supporting  the  remote 
assessment of callers to urgent and emergency services. The NHS Pathways 
system is widely used in the following settings: 

▪  NHS 111 (ambulance services including NEAS) 
▪  999 (ambulance services, including NEAS) 
▪ 
▪  NHS 111 Online 
▪  To assist in the management of patients presenting to urgent care or 

Integrated Urgent Care Clinical Assessment Services 

emergency departments 

The  system  is  owned  by  the  Department  for  Health  and  Social  Care  and 
delivered  by  the  Transformation  Directorate  of  NHS  England.  NEAS,  as  a 
service commissioned by NHS England and host system suppliers enter into 
licences with the Secretary of State for Health and Social Care, allowing them 
to embed NHS Pathways within their products. The system is maintained by a 
group  of  experienced  staff  most  with  an  urgent  and  emergency  care 
background.  All 
licensed 
practitioners. 

the  clinical  authoring 

team  are  registered, 

To this extent NEAS have limited ability to fully respond to this specific concern 
and will defer to the response via NHS England. We will of course fully liaise 
with our colleagues in NHS England to provide any additional information that 
will aid their understanding of the concerns as a result of the inquest. NEAS are 
members of a national NHS Pathways User Group and feed concerns into an 
issues 
system 
development/improvement.  

learning  and 

log  which 

is  used 

consider 

to 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Qual ity Commission (Provider ID: RX601).  

  
 
 
 
 
 NHS  Pathways  also  have  a  national  governance  group,  which  involves  all 
healthcare  professional  and  college  representation,  who  assess  the  clinical 
evidence  to  develop  new  pathways  or  make  changes  to  the  established 
pathways. The NHS Pathways team are aware of this case and we have raised 
the matter via the NHS Pathways issues log and await their response.  

3.  It  is  unclear  as  to  whether  Margaret  Huntley  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. 

I am aware the Regulation 28 report for the prevention of future deaths was issued 
to  other  organisations  including  the  Royal  College  of  General  Practitioners.  In 
regard  to  the  influence  NEAS  has  upon  this  concern,  this  is  not  something  an 
Ambulance Trust would issue nor can directly influence. My response to the fourth 
concern  links  in  with  the  awareness  of  emergency  ambulance  crews  and 
accessing/sharing such information with our crews. As an Ambulance Trust we do 
not prescribe or issue long-term steroids and therefore do not have reasonability 
for  issuing  steroid  emergency  cards.  As  part of  the  work  I  have explained  in  the 
response to the fourth concern, we will continue to liaise with system partners to 
ensure information is accessed and shared appropriately across organisations.  

To ensure consistency with existing public messaging we have included a link to 
the Addisons Self Help Group website on the NEAS website and have undertaken 
an awareness campaign via our social media platforms. 

4.  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. 

I  am  aware  the  Regulation 28  report  for  the prevention  of  future  deaths  was 
issued  to  other  organisations  including  the  Royal  College  of  General 
Practitioners.  In  regard  to  the  influence  NEAS  has  upon  this  concern  I  can 
confirm that upon attending a patient and completing an electronic patient care 
record, these clinical records are securely transferred to the patients General 
Practice and uploaded to the Great North Care Record. This ensures that any 
emergency ambulance attendance is shared with the General Practice to assist 
with  the  continuity  of  care  and  update  the  patients’  clinical  records.  These 
records  would  include  the  assessment  and  treatment of  the  attending  NEAS 
emergency ambulance crews. Whilst this is the flow of information from NEAS 
into  General  Practice,  it  is  important  to  know  that  attending  emergency 
ambulance crews can access systems including GP Connect and Great North 
Care Record. This does however rely upon NEAS having awareness to check 
for  such  information  if  not  already  known  and  a  ‘flag’  been  shared  with  the 
attending crew.  

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Qual ity Commission (Provider ID: RX601).  

 
 
 
 
 
 
 
 During our review we have also considered the associated guidance from the 
Association of Ambulance Chief Executives (AACE), specifically the publication 
relating to ‘red flagging’ of patients with specific clinical conditions. Whilst we 
recognise  and  share  the  concerns  around  the  additional  overhead  the 
maintenance  of  flagging  and  care  plan  management  places  on  NEAS,  we 
believe that until an automated regional based solution can be provided, we will 
continue to  accept  care  plans  and  flags  from  our  providers,  in  the  interest  of 
aiding our crews with the delivery of patient care.  

Linked  with  the  above,  our records  show that  the  majority  of  care  plans  and 
flags are created by our wider system partners, a North East and North Cumbria 
Integrated  Care  Board  (ICB)  wide  group  has  been  established  and  is  now 
meeting  regularly  to  improve  the  flagging  challenges  and  a  coordinated 
approach to standardise and centralise the production, storage, and access to 
care plans for consideration by the North East and North Cumbria ICB Digital 
Board. 

It is important to mention that both information sharing platforms, GP Connect 
and Great North Care Record, do not presently have full patient details or care 
plan  documents  from  all  providers.    The  North  East  and  North  Cumbria 
Integrated Care Board is leading on a ‘levelling up’ project for all providers in 
our region. NEAS will continue to work with wider system partners to develop 
more effective centralised means of region wide flagging and care plan sharing. 

I  hope  this  response  provides  you  and  the  family  with  the  appropriate  level  of 
assurance that  as a  Trust  we  are  dealing  with  the  concerns  highlighted  within  your 
report.  If  it  would  be  helpful,  we  would  gladly  arrange  a  visit  to  our  Emergency 
Operations Centre to show you the NHS Pathways system in operational use as well. 
May I once again pass on my sincere condolences to the family of Margaret. If we can 
, 
be  of  any  further  assistance  then  please  do not  hesitate  to  contact 
Head  of  Regulatory  Services  via  email  at 
  or 
telephone 07891 469571.  

Yours sincerely,  

Chief Executive 

Enclosures: 

JRCALC Standard for Guideline Development 
National Patient Safety Alert - Steroid Emergency Cards 
Medical Directorate Alert - MED/0142 Steroid Dependent Patients 
Clinical Directorate Alert - Adrenal Insufficient Patients 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Qual ity Commission (Provider ID: RX601).

Mr Paul Appleton 
Assistant Coroner for Teesside and Hartlepool  
The Coroner’s Service 
Middlesbrough Town Hall 
Albert Road 
Middlesbrough 
TS1 2QJ 

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

03/10/2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Margaret Huntley who died 
on 10 December 2022  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  13 
August  2024  concerning  the  death  of  Margaret  Huntley  on  10  December  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Margaret’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Margaret’s 
care have been listened to and reflected upon.   

Your  Report  confirmed  that  Margaret’s  death  was  contributed  to  by  delays  in 
identifying  that  she  required  exogenous  steroid  medication,  and  delays  in  the 
prescription  and  administration  of  exogenous  steroid  medication.  Accordingly,  your 
Report  raised  concerns  around  the  understanding  of,  and  response  to,  suspected 
steroid  insufficiency  /  Addison’s  Crisis  amongst  ambulance  service  staff.  I  have 
responded to each of your concerns below, in so far as they fall within NHS England’s 
remit.  

1. Ambulance  service  staff’s  understanding  of  the  importance  of  steroid 
medication  and  responding  to  suspected  steroid  insufficiency  /  Addison’s 
Crisis.  

NHS  England  is  aware  that  the  Ambulance  Service,  through  the  Association  of 
Ambulance  Chief  Executives  (AACE)  and  the  AACE  National  Ambulance  Services 
Medical Directors’ group (NASMeD), has engaged with the Addison’s Disease Self-
Help  Group  and  the  Pituitary  Foundation,  to  ensure  patients  are  aware  of  the 
importance of informing a 999 call handler or any healthcare professional that they are 
steroid dependent. Where a patient shares information with an emergency call handler 
that they are steroid dependent, advice can then be given to that patient to follow the 
instructions  provided  by  their  doctor  about  self-administration  of  their  emergency 
steroids. 

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) produces clinical 
guidelines  for  UK  paramedics  and  includes  guidelines  for  the  recognition  of  and 
management of adrenal crisis and of patients who are steroid dependent.   

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
  
 I note that you have also sent your Report to the AACE, who would be the appropriate 
organisation to provide further information on this.   

My  regional  North  West  colleagues  have  also  engaged  with  North  East  and  North 
Cumbria  Integrated  Care  Board  (hereafter  “ICB”)  on  the  concerns  raised  in  your 
Report, who we understand will be responding to the Coroner directly.  

We  understand  that  North  East  Ambulance  Service  NHS  Foundation  Trust  (NEAS) 
are working internally to address communications around steroid medication, focusing 
on key messages around adrenal crisis, and that workshops are also planned. Work 
is also underway to establish a more effective system for the monitoring of guidance 
issued to their staff members.  

2. Call triaging guidance for ambulance service staff regarding patients who are 

prescribed steroid medication 

NHS  Ambulance  Services  are  required  to  process  999  calls  through  an  approved 
triage system.  There are currently two systems approved in England for primary 999 
assessments:  NHS  Pathways  and  the  Advanced  Medical  Priority  Dispatch  System 
(AMPDS).  

In  AMPDS,  the  call  handler  will  be  prompted  to  remind  callers  who  are  triaged  as 
‘Acute adrenal insufficiency / crisis or Addison’s disease’ to do what their doctor has 
instructed for these situations. 

The  NHS  Pathways  triage  product,  which  was  used  in  Margaret’s  case,  is  built  to 
progress  through  a  clinical  hierarchy  of  urgency.  This  means  that  life-threatening 
symptoms or problems are assessed first, and less urgent symptoms or problems are 
assessed sequentially thereafter. The endpoint of an assessment is reached when a 
clinically  significant  factor  cannot  be  ruled  out,  and  so  a  “disposition”  (outcome)  is 
reached. Dispositions range from an Emergency Ambulance to Self-Care. 

Questions  on  past  medical  history  or  details  regarding  prescriptions  are  utilised 
sparingly across  the  system  and  are  only enquired about  where necessary. This is 
because  NHS  Pathways  is  a  ‘triage’  rather  than  a  ‘consultation’  tool,  and  the 
assessment is primarily based on the patient’s presenting symptoms at the time of the 
call. 

If a patient is unconscious, the lowest disposition that can be reached is a Category 2 
emergency ambulance response, and questions around adrenal insufficiency would 
not be asked before reaching the disposition (because this would not impact upon the 
category of ambulance required). However, the system does go on to ask whether the 
caller has known adrenal insufficiency following  an ambulance dispatch. Where this 
question  is  answered  as  “yes”,  specific  “in-line”  advice  about  administration  of  an 
emergency steroid kit is given to the caller. 

If a patient with adrenal insufficiency is conscious at the time of a call, the symptoms-
based triage assessment proceeds based on clinical hierarchy. Patients with adrenal 
insufficiency  are  often  knowledgeable  about  their  condition  and  have  specific 

 
 instructions from their specialist on when and how to use emergency treatment kits, 
so if they volunteer this information, this should be treated as a complex call as detailed 
below in respect of steroid cards. 

3. Steroid Emergency Cards 

We note that your concerns are not limited to adrenal insufficiency, but that you have 
also raised a concern over the awareness and usage of  Steroid Emergency Cards. 
NHS  England  issued  a  National  Patient  Safety  Alert  in  August  2020  regarding  the 
introduction  of  a  new  Steroid  Emergency  Card  to  support  early  recognition  and 
treatment  of  adrenal  crisis 
is  available  here: 
https://www.england.nhs.uk/publication/national-patient-safety-alert-steroid-
emergency-card-to-support-early-recognition-and-treatment-of-adrenal-crisis-in-
adults/. 

in  adults.  The  Alert 

It is the responsibility of the Care Quality Commission (CQC) to ensure that the actions 
within an alert have been actioned by NHS provider organisations. However, it is NHS 
England’s understanding that all Trusts are now compliant with this particular Alert.    

The  Alert  prompted  a  review  of  the  content  in  the  NHS  Pathways  system  when  a 
patient notifies the call taker that they have a steroid card. It was agreed that, should 
the patient declare that they have been issued with a steroid card, this would meet the 
criteria for a “complex call” which would require clinical input.  

In addition, ambulance clinicians have access to patient care information (a Summary 
Care Record (SCR) or urgent care plan) where important clinical information can be 
uploaded  by  a  patient’s  GP,  or  in  some  cases  by  the  patient,  and  can  include 
information about steroid dependency. 

NHS England understands that NEAS will be promoting use of the Addison’s Self Help 
Group  and  their  awareness  raising  page  for  steroid-dependent  patients,  which 
encourages patients to ensure that their SCR is up to date and to carry a Steroid Card 
and  emergency  injection  kit:  https://www.addisonsdisease.org.uk/newly-diagnosed-
paramedic-information. 

4. GP  awareness  of  their  ability  to  alert  ambulance  service  staff  to  specific 

patient health conditions such as steroid insufficiency  

My colleagues from NHS England’s National Primary Care Team have been asked to 
consider this concern and whether any actions are required. I also note that you have 
sent your Report to the Royal College of General Practitioners, and we would welcome 
their input and advice on this issue.  

However, it should be noted that ambulance services have expressed a preference 
towards information being documented on a patient’s SCR or urgent care plan, rather 
than through alerting.  

In Margaret’s case, we understand from the ICB that an alert was in place but was 
difficult to identify. The ICB will be taking the circumstances surrounding Margaret’s 
death  to  their  GP  learning  sessions  and  they  are  also  considering  a  system-wide 
safety alert relating to this.  

 I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  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  events,  such  as  the  sad  death  of 
Margaret, are shared across the NHS at both a national and regional level and helps 
us to 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