Missed Medication & Human Rights – Case Study

Our clients v Sheffield Teaching Hospitals NHS Foundation Trust

Year of incident: October 2016

Date of Settlement: December 2017

Acting: Scott Haslam, Assistant Solicitor at Wake Smith Solicitors


We acted for the children of the Deceased.  The Deceased was admitted to the Frailty Unit at the Northern General Hospital in October 2016 with a suspected urinary tract infection which had caused her to become confused.

The Deceased was prescribed Hydrocortisone medication for Addison’s disease (adrenal insufficiency).  She had been on the medication for a number of years and was usually able to manage it herself.  As a result of her confusion, she was reliant on hospital staff to administer the medication.

Prior to her death, Hydrocortisone should have been given on 18 occasions but she only received 5 doses.  Her condition deteriorated but medical and nursing staff failed to recognise that she hadn’t been given her prescribed medication.  They also failed to follow the hospital’s policy for escalating a patient’s care to a more senior level.  This would have ensured that she was reviewed more often and by a doctor.

The Deceased’s deterioration was not recognised until she was so unwell that she was unconscious and her blood pressure could not be recorded. The missed medication was noted and she was prescribed IV Hydrocortisone.

Unfortunately, the Deceased passed away shortly thereafter.


The Deceased’s condition deteriorated over the course of a week.  She became increasingly unwell and eventually became unresponsive.  She died as a result.

The Deceased’s children were left with a number of questions about her death and the hospital conducted a Serious Untoward incident Investigation.  A report was subsequently prepared which accepted a number of failings including:

  • There was no evidence medical staff noticed the Hydrocortisone medication had not been given as prescribed;
  • Missed opportunities to escalate the Deceased’s care as a result of failing to follow hospital policy and ‘acutely low nurse staffing levels’; and
  • Staff had not received recent training regarding the escalation policy. Some nursing staff could not recall having received any such training.

The matter was referred to HM Coroner and an Inquest into the death concluded that ‘there were significant failings in the care of [the Deceased] in that Hydrocortisone, a critical medication, was only given to her on 5 out of 18 occasions.  Her condition, and her need for this medication, was known.  Failing to escalate the fact this medication was not being taken was a gross failure, and was neglectful and this failure to take action had a clear and direct causal connection to her death.’

Expert Evidence:

Wake Smith Solicitors were able to deal with the matter without the need to resort to expert evidence, utilising the information set out in the Serious Untoward Incident Report and the Coroner’s Narrative Conclusion.

The Proceedings:

A claim for negligence was pursued on behalf of the Deceased’s Estate.  Claims were also pursued on behalf of her children under the Human Rights Act 1998 for a breach of the Deceased’s ‘right to life’.

The matter was settled out of court and within 6 months of Wake Smith Solicitors being instructed.


The claim settled for a value of £20,000 plus reasonable costs.

Client comment:

“The service provided by the whole team, especially Scott Haslam, made a very difficult and trying time so much more easy to deal with thanks to your utter professionalism. Thank you and I would definitely use your service again.”

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