“(numbered separately in respect of each organisation, who are required to respond to each…”

The coroner’s concerns

(numbered separately in respect of each organisation, who are required to respond to each of the numbered paragraphs relating to them): 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 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. West Midlands Ambulance Service University NHS Foundation Trust (WMAS) 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. 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). Safetynetting 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. 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. 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. Association of Ambulance Chief Executives (AACE) 1) The relevant JRCALC (Joint Royal Colleges Ambulance Liaison Committee) guideline for steroid dependent patients (which was disclosed by WMAS as part of inquest proceedings) places very little emphasis on the importance of administering steroid replacement therapy to patients who, although not presenting as acutely unwell, are at risk of developing an acute adrenal crisis, owing to them suffering from trauma or physiological stress. The relevant section (contained in bullet point 2 of the ‘adminis

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

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judiciary.uk, Prevention of Future Deaths reports, 2023-0125

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0