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Patient safety failures can be fatal


ADSHG

  • Misunderstandings about the risks to someone who is steroid-dependent can occur at many points within the care pathway – from the ambulance service personnel through to medical clinicians – and can easily become fatal. Important lessons can be learnt from these tragic cases.

Robin Brett safety failures
This five-minute video, produced by the Royal Bournemouth and Christchurch Hospitals NHS Trust, describes one tragic case where omission of steroids resulted in the death of a vulnerable young man who was steroid-dependent with complex comborbidities.

 

 

 


The ADSHG wishes to thank the family of Robin Brett and Dr Tristan Richardson for permission to publish this video.

 

 



Adam Cash's story
ADSHG-patient_safety_failures_adam_artic
Ambulance Today has published a 6 page feature about the death of this 21 year old, who died just over a year after his Addison's diagnosis. Misunderstandings on the part of ambulance staff about the risks to his steroid-dependence from a vomiting illness were a significant contributing factor to his arguably preventable death from a norovirus infection.

 

 

This poignant feature explores the various factors contributing to his death, which included misjudgements on the part of the 999 call handler and the first response crew, his family's lack of familiarity with his condition and how to respond to the risks of vomiting, as well as Adam's heightened vulnerability to circulatory complications from the norovirus infection, due to an undetected cardiac irregularity. The lessons from this tragedy are discussed in the Editor's Comment on p3, while the feature article, 'An Inspirational Young Man', begins on p11.

 

Clare Cooper's story

 

Clare Cooper was just 6 weeks away from her 24th birthday when she collapsed at home and died from undiagnosed Addison's. Her advanced symptoms had mistakenly been attributed to anorexia, for which she had been assessed at an eating disorder unit. You can read her story on this memorial website maintained by her family. Since thanks to the Cooper family for permission to share her story.



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The Addison’s Disease Self-Help Group is the support group for people with Addison’s disease or adrenal insufficiency and their families in the UK and Ireland.The group was formed in 1984 and is a UK registered charity no. 1179825.

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