Failure to diagnose: Addison disease.

On 11 May 2007, the State Coroner of Western Australia, made a number of recommendations regarding the recognition of serious illnesses in a general practice setting, and the supervision of medical practitioners undertaking prevocational training. The recommendations arose out of a Coronial Inquest into the death of a 16 year old patient from Addison disease. This article discusses the case and the recommendations made by the coroner.