19. Mr R tells us that Mrs R had a known adrenal insufficiency and was prone to Addisonian crisis. Adrenal insufficiency, also known as Addison’s disease, is a rare disorder which occurs when the adrenal glands do not produce enough cortisol.
20. Cortisol is a steroid hormone which helps control the immune function of the body, as well as the ability to withstand injury and illness.
21. Addisonian crisis, also known as adrenal crisis, is a sudden worsening of symptoms which can occur in patients with adrenal insufficiency when the levels of cortisol in the body are insufficient in the context of an illness (like an infection) or any other severe physical stress (such as an injury or operation). Adrenal crisis needs to be treated as a medical emergency, as it can be fatal.
22. Mr R is concerned that Mrs R’s medical history was not taken into consideration during her admission, especially when she began to deteriorate, despite him raising his concerns with the doctors.
23. We have reviewed Mrs R’s care with our endocrinology adviser.
24. The RCP guidance for the prevention and emergency management of adult patients with adrenal insufficiency explains that for those with moderate intercurrent illness (e.g., a fever or an infection requiring antibiotics) sick day rule one should be followed, which includes doubling the usual daily glucocorticoid use. Our endocrinology adviser confirmed that prednisolone is a glucocorticoid preparation known to have rapid absorption.
25. It is evident in the admission documents that the medical and nursing teams recognised Mrs R’s background of adrenal insufficiency. On the first day of admission, Mrs R’s prednisolone dosage was increased in response to her presentation with infection. On the first day of admission, the dose was increased to 15mg, and then to 30mg.
26. Our endocrinology adviser explains that a daily dosage of 20mg is sufficient in the context of a moderate infection, and so we consider at this point Mrs R was receiving adequate steroid cover in line with the RCP guidance.
27. We understand that in this situation, either prednisolone or hydrocortisone can be used. As Mrs R was already taking prednisolone, our endocrinology adviser explains it was reasonable to keep prescribing this due to its good gut absorption. We can see from the records that Mrs R was able to take tablets, and so at this point of her admission, it was appropriate for tablets to be prescribed, as there were no known issues preventing her from taking them.
28. We also consider that it was appropriate for general physicians to manage Mrs R’s adrenal insufficiency, in the context of an intercurrent illness, as there are no indications Mrs R required specialist endocrine input during her admission as per the RCP guidance.
29. Our endocrinology adviser explained that the clinical features of adrenal crisis and sepsis are similar, and sepsis can bring on an adrenal crisis if not adequately treated. They also explained that sepsis can reduce the gut absorption of oral prednisolone, and therefore, in the context of a deterioration, high dosage IV hydrocortisone should be considered.
30. The RCP guidance recommends 100mg of IV hydrocortisone at onset of deterioration, followed by initiation of a continuous infusion of IV hydrocortisone 200mg over 24 hours, or 100mg of hydrocortisone intramuscularly followed by 50mg every six hours intramuscularly or by IV, in line with sick day rule two for severe intercurrent illness.
31. For this reason, we have explored whether it was evident that Mrs R was deteriorating, and whether an opportunity was missed to consider the provision of IV hydrocortisone.
32. We looked at this aspect of the complaint with our geriatrician adviser as there are no indications Mrs R required specialist input during her admission.
33. NICE CG50 (Acutely ill adults in hospital: recognising and responding to deterioration) explains that:
• Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. (1.3) • Physiological observations should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient. (1.3) • The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy (1.3)
34. Initially, Mrs R appeared to be responding to treatment, and this is shown through her NEWS. The scores remained between zero and four from 20 February to her death on 24 February. Our geriatrician adviser explained that Mrs R was not presenting with clear or typical signs of sepsis and in looking at Mrs R’s observations from the 23 to 24 August, her NEWS was actually improving.
35. We consider this aspect of Mrs R’s care was in line with NICE CG50 as Mrs R’s physiological observations were being tracked, and the scores reflected the level of care she required.
36. Although Mrs R’s NEWS was not increasing, blood results from 23 August had indicated worsening of infection markers and kidney tests. We can see from the records that the results were acted upon with the insertion of a midline venous catheter, a change in antibiotics from oral to IV administration, and additional IV fluids.
37. Mrs R continued to receive IV fluids, which stopped at 3am on 24 August. The records show that she was also receiving fluids from other sources as well. On 24 August before Mrs R sadly died, she had 600mls fluid orally and also received 225mls of fluids from her IV antibiotics. Therefore, we can see over the 24-hour period before she died she received 2025mL fluid which our geriatrician adviser confirmed was a reasonable input in the context of Mrs R’s presentation.
38. Our geriatrician adviser also confirmed the actions taken in response to the blood results were appropriate, and we consider providing these treatments was in line with the GMC’s Good Medical Practice guidance which states:
“You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:
a) adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values, where necessary, examine the patient b) promptly provide or arrange suitable advice, investigations, or treatment where necessary c) refer a patient to another practitioner when this serves the patients needs”
39. In the last medical review carried out before Mrs R died, we can see that the doctor reviewed her clinical condition, observations, fluid intake, and provided advice to consider further IV fluids if Mrs R’s acute kidney injury (AKI) worsened at any stage.
40. This demonstrates that a plan was in place to continue monitoring Mrs R’s fluid intake and kidney function. Additionally, the clinical team had a plan in place to discuss the choice of antibiotics with the microbiology team if Mrs R began to deteriorate further.
41. We consider the plan for Mrs R’s care was in line with the GMC’s Good Medical Practice guidance, point 15 which we have outlined in point 39 of this report.
42. Overall, we consider there were no signs Mrs R was deteriorating or developing sepsis, and so there were no indications for the team to consider a change in treatment, to trigger a sepsis review, or to consider changing to high dosage IV hydrocortisone. Mrs R was monitored and treated in line with the guidance we have quoted in our report. For this reason, we do not uphold this complaint.
43. We hope the information provided in this report is reassuring for Mr R that nothing more could have been done to prevent the sad outcome of this case and we give our sincere condolences for his loss.