This case study follows an adolescent with hypopituitarism who experienced inadequate hydrocortisone coverage following surgery. Despite ongoing education and an experienced family, uncertainty around medication administration in hospital followed by failure to recognise signs and symptoms after discharge placed the young person at significant risk. We will explore the risks associated with perioperative management of adrenal insufficiency and highlight an important challenge for clinicians - education does not always translate into action when families are faced with real-world situations.