The death of a man from sepsis during an adrenal crisis has been partly blamed on a communication breakdown between his GP and an endocrinologist over the need for emergency hydrocortisone.

Francis Stewart had originally been diagnosed with hypopituitarism, a result of the radiation therapy he had undergone for a medulloblastoma at the age of two.

He was being treated by an endocrinologist at the Peter MacCallum Cancer Centre, in Melbourne, for thyroid and testosterone deficiencies, during which time his endocrinologist prescribed corticosteroid replacement therapy for previously untreated adrenal insufficiency, in addition to testosterone and thyroxine.

The specialist said Mr Stewart was well-informed about adrenal insufficiency, had been given hydrocortisone for emergency administration and had a “stress cover letter”, explaining to doctors his need for additional steroid cover during any episode of ill health.