“Royal Cornwall Hospital (RCHT) • The concern is the inadvertent reduction of steroid…”

The coroner’s concerns

– (1) Royal Cornwall Hospital (RCHT) • The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies. • The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake. • RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error. (2) The National Institute for Clinical Excellence (NICE) • The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence • BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines. • Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone. • In relation to a number of sections in the Prednisolone guidance it was found as follows • The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease • The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis • The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.

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

Source

judiciary.uk, Prevention of Future Deaths reports, 2023-0135

Added to Minute Book

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