Michael Pegg

Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Michael Leslie Pegg who died on 15 January 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 January 2024 concerning the death of Michael Leslie Pegg on 15 January 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Michael’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Michael’s care have been listened to and reflected upon.

In your report you raised concerns that those treating Michael failed to follow National Institute for Health and Care Excellence (NICE) guidelines relating to the treatment of those with adrenal insufficiency conditions who are being treated for intercurrent illness. NICE are responsible for producing these clinical guidelines and NHS Trusts and bodies are expected to pay due regard to NICE and Royal College guidelines. As you note in your Report, there is existing guidance on this issue from NICE. They are also due to publish updated guidance on Adrenal insufficiency: acute and long-term management later this year.

NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.

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

25 March 2024

The work above also resulted in the publication of the National Patient Safety Alert (NatPSA), which includes the specific action that ‘Providers that treat patients with acute physical illness or trauma, or who may require emergency or elective surgical or other invasive procedures, including day patients, should review their admission/assessment/examination/clerking documentation to ensure it includes prompts to check for risk of adrenal crisis and to establish if the patient has a Steroid Emergency Card.’ Trusts were expected to implement actions around this specific alert by 13 May 2021 and Worcestershire Acute Hospitals NHS Trust is recorded as being compliant with this. We also note that it appears that the Trust has an internal guideline on the management of adrenal insufficiency, published in March 2022. The Royal College of Emergency Medicine (RCEM) has also issued professional guidance on Addisonian Crisis.

Your Report also raised the concern that Michael received treatment in the Resus Corridor and in the Major’s Overflow area and that the noisy and crowded conditions put proper treatment of patients at risk. NHS England recognises that services across the NHS are currently facing significant pressures. NHS England is committed to improving patient experience within hospitals and in January 2023 we published a two- year Delivery plan for recovering urgent and emergency care services. The plan aims to relieve pressures on emergency departments by:

• Growing the workforce available for 111 online and urgent call services to offer support, advice, diagnosis and referral.
• Expanding services within the community to prevent avoidable A&E admission. This will include more joined-up urgent care within the community and use of virtual wards.
• Helping people access the right care first time, ensuring that 111 is the first port of call and reducing the need for people needing to go to A&E.
• Growing capacity and number of beds within hospitals to relieve pressures on A&E Departments.

NHS England would refer you to the Trust on what actions are being taken locally to address your concerns. We have been sighted on their Serious Investigation Report and Action Plan and note that they have taken learnings around Emergency Department crowding and improving end-of-life care for patients and are reviewing staffing levels in the Overflow Area and Acuity.

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.

Dear Mr Reid

Re: Mr Michael Pegg deceased Regulation 28 Report to Prevent Future Deaths

Thank you for forwarding on your Regulation 28 report. I have read your report with great care and note the concerns that you have raised as a result of the coronial inquiry into the death of Mr Michael Pegg.

In your Regulation 28 report you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT) and I will respond to these concerns below, as a sequence, where appropriate.

Concerns

1) The steroid treatment provided to Mr Pegg during this admission fell far short the guidelines.

2) None of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case. Unless action is taken to ensure clinicians employed by the Trust are aware of, and are able to apply these Guidelines, there remains a risk that another patient with adrenal insufficiency may die in similar circumstances.

3) Patient’s wellbeing may be put at risk because a Hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines

The Trust has now implemented both further learning and additional checks, to ensure that steroid treatment provided to future patients will not fall short of the NICE Guidelines in the future. I have noted the actions taken below and I hope that they will ensure clinicians employed by the Trust are aware of, and are able to apply the relevant Guidelines in the future.

• Steroid replacement therapy has been discussed in both the Trust Patient Safety Incident Response Group and the Deteriorating Patient, Resuscitation, End of Life and Mortality Group on

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD Office of the Managing Director

several occasions since Mr Pegg’s sad death. Discussions included the importance of the adult patient document in the Emergency Department which was updated in June 2023. This now

includes a time critical medications (highlighted steroid replacement) (please see appendix 1 attached). This is automatically included for all adults presenting to the Emergency Department.

• A “detect and reflect” document and “time critical medication safety flash” have been circulated to all Emergency and Medical staff to raise awareness of the need for steroid replacement therapy (appendix 2, 3). These are displayed in the Emergency Department handover area.

• Steroid replacement (and other time critical meds) has been highlighted in effective handover in ED in 2023 and will be repeated (appendix 4) to raise and maintain awareness for all medical staff working in the ED.

• The Trust is due to move to an electronic patient record in the Emergency Department in Autumn 2024 – time critical medications including steroids are due to be incorporated into this.

• The Emergency Departments on both sites are participating in a Royal College of Emergency Medicine audit looking at the prescribing and administration of time critical medicines, including steroids. This audit will provide a “benchmark” for the Trust and also highlight areas where further improvement is required. The audit is still in data collection phase but results will be available later in the year.

• The Acting Chief Medical Officer will be attending the Induction for new doctors in August in order to highlight this area of focus for the Trust for all junior doctors rotating into our hospitals.

• The Medical Examiners, at the request of the Trust, are working with Adrenal Insufficiency/Steroid Replacement as one of their high priority conditions which means that any concerns identified with steroid replacement will trigger further case review. The focus therefore remains on this area and will continue to be so until we are fully assured that our processes for identifying and managing this condition are effective.

• The “overflow area” of the ED is no longer being used, having closed in October 2023.

As a Trust, we have reflected on our practices as a result of Mr Pegg’s death. I hope the above demonstrates our commitment to ongoing learning and reassurance of our commitment to reinforce the NICE guidelines in relation to steroid treatment for patients.

I trust that the foregoing has adequately addressed the Regulation 28 report issued subsequently to the inquest into the death of Mr Pegg.

Should you require any further information in relation to this matter, please do not hesitate to ask.

I confirm that I have not forwarded a copy of this response to any other Interested Person and would therefore be grateful if you could do so, as appropriate.

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD Office of the Managing Director

I also confirm that the Trust is content for both the regulation 28 report and the response to be released or published should the Chief Coroner wish.