Finding into death of Francis John Stewart

38y · Male·Sepsis complicating bronchopneumonia and chest wall abscess in the setting of an adrenal crisis in a man with secondary endocrinopathy following chemoradiation for a medulloblastoma in childhood

A 38-year-old man with secondary adrenal insufficiency from childhood chemoradiation died from sepsis complicating a chest wall abscess and bronchopneumonia, precipitated by an adrenal crisis. He presented to his GP with a large chest abscess on 10 July 2018 and underwent incision and drainage on 13 July 2018. Although his GP advised increased prednisolone during acute illness, there was inadequate documentation of this advice, no recorded vital signs during multiple consultations, and the GP's medical records did not highlight his adrenal insufficiency as a critical alert. The patient had gastrointestinal symptoms (nausea) on 14 July, a non-specific sign of impending adrenal crisis that was attributed to antibiotics. The coroner found the death potentially preventable with appropriate additional steroid replacement and careful monitoring. Key deficiencies included: poor documentation of clinical advice, absent vital sign recordings, failure to adequately alert to adrenal insufficiency in primary care records, and insufficient awareness among GPs of adrenal crisis risks during acute illness.