Recurring concern

Unreliable clinical assessment and management of eating disorders

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First reported 25 Jul 2014•Latest report 14 Feb 2024

Definition

What this concern includes

Includes failures in eating-disorder clinical assessment and management controls, including triage consideration of organic and other alternative diagnoses, condition-specific clinical guidance, assessment of treatment engagement and risk, and decisions about appropriate medical or specialist management.

Not included

Excludes failures limited to making or tracking referrals or escalation to eating-disorder services where the broader assessment and management process is not deficient.
Excludes failures specific to ARFID recognition or specialist support, which belong to the narrower ARFID concern.
Excludes generic mental-health, nutrition, communication or documentation deficiencies unless they directly impair eating-disorder assessment or management.
Excludes treatment-quality or access failures after the eating-disorder assessment and management process has operated reliably.

Reports: 5
Individual concerns: 8
Date range: 2014–2024
Stated actions: 24

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

NHS Greater Manchester Integrated Care Board3

Royal College of Psychiatrists3

NHS England2

Academy of Medical Royal Colleges1

British Association For Counselling And Psychotherapy1

Department for Education1

Greater Manchester Mental Health NHS Foundation Trust1

Medicines and Healthcare products Regulatory Agency1

National Institute for Health and Care Excellence1

NHS Bury Clinical Commissioning Group1

NHS Surrey and Sussex Integrated Care Board1

Northern Care Alliance NHS Foundation Trust1

Priory Group1

Royal College of Pathologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

14 Feb2024
Manchester South
Concerns raised1
1. Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Continue working with systems and healthcare professionals to support wider adoption of the MEED guidance.
  Stated by Department for Education and Department of Health and Social CareStated in progress
2. Action
  Implement revised paediatric medical guidance for nutritional screening and medical management.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
AI-generated summary

Alfie Anthony Kevin Nicholls · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alfie Anthony Kevin Nicholls, a child with autism and a severely restricted diet, collapsed at home on 17 December 2021 and died at Stepping Hill Hospital despite attempts to resuscitate him. A post-mortem examination found significant malnutrition, and the report identified concerns about poor communication between professionals and the family, limited recognition and understanding of ARFID and medical risk, and insufficient coordinated support and resources.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry
Wider context from the report
“7. ARFID, the Inquest was told, could lead to medical emergencies in eating disorders (MEED). The evidence given at the Inquest was that whilst this concept had been the subject of guidance amongst Psychiatrists it had been less publicised and there had been far less guidance by other Royal Colleges. In particular the Inquest was told that MEED needed to be far better understood by medical professionals in acute settings such as Emergency Departments and Paediatrics to avoid a situation where the impact of ARFID and the medical risk it posed was not understood until it was too late. ”
Source location
Alfie Anthony Kevin Nicholls · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue working with systems and healthcare professionals to support wider adoption of the MEED guidance.

Verbatim wording from the response
“You highlighted the importance of raising awareness of the medical emergencies in eating disorders (MEED) guidance and I can assure you that NHS England continues to work with systems and healthcare professionals to support the wider adoption of the MEED guidance. This commitment was recently reiterated in the Suicide prevention in England: 5-year cross-sector strategy which was published last year.”

Source location
Response from Department of Health and Social Care
Page 4 · response
Published 22 February 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement revised paediatric medical guidance for nutritional screening and medical management.

Verbatim wording from the response
“• Revised medical guidance for paediatricians has been put in place regarding nutritional screening & medical management.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 22 February 2024
Open published response
8 Dec2023
Manchester North
Concerns raised1
1. Failure to consider cyclizine addiction in eating disorder services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Communicate the potential cyclizine addiction risk to members through newsletters, faculty communications and other suitable channels.
  Stated by Royal College of PsychiatristsStated planned
2. Action
  Raise the potential cyclizine addiction risk with mental health organisations and bodies responsible for mental health system oversight.
  Stated by Royal College of PsychiatristsStated planned
AI-generated summary

Charlene Roberts · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Charlene Roberts died at Fairfield General Hospital on 12 January 2023 after suffering cardiac arrest during an inpatient admission; her cause of death was confirmed as cyclizine toxicity, with aspiration pneumonia, anorexia and factitious disorder also recorded. The principal concerns included the availability and prescribing of cyclizine, limited professional understanding of cyclizine dependence and the use of local intelligence systems for non-controlled drugs, and the lack of a commissioned community pathway for obtaining blood samples from compromised patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to consider cyclizine addiction in eating disorder services
Wider context from the report
“The court was made aware of the research conducted in 2009 as published in the journal PNS, “Proceedings of the Nutrition Society”, “Cyclizine dependence in patients with complex nutritional requirements” Thursby-Pelham, De Silva, Stroud and Fine, 23 July 2009. This identified cyclizine dependence in four female patients who all had complex nutritional problems. Whilst it is acknowledged that this is one study and as stated cyclizine addiction is rare, it was not something which had been considered before Charlene’s addiction by the Eating Disorder Service. For the Manchester Eating Disorder Service there is now a greater awareness of cyclizine. This may be important nationally given its use as an anti-emetic. ”
Source location
Charlene Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Communicate the potential cyclizine addiction risk to members through newsletters, faculty communications and other suitable channels.

Verbatim wording from the response
“Therefore, will be using mechanisms to communicate this potential risk to our members, such as through our College Newsletters, Faculty specific communications and any other opportunity where we can make this issue more widely known.”

Source location
Response from Royal College of Psychiatrists
Page 2 · response
Published 12 December 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Raise the potential cyclizine addiction risk with mental health organisations and bodies responsible for mental health system oversight.

Verbatim wording from the response
“We will also, where possible, raise it with mental health organisations themselves as well as those who have responsibility and oversight for the mental health system and who will have routes by which this information can be disseminated.”

Source location
Response from Royal College of Psychiatrists
Page 2 · response
Published 12 December 2023
Open published response
25 Mar2022
Blackpool and the Fylde
Concerns raised2
1. Lack of specific guidance for GPs managing eating disorder patients who are not engaging with treatment
2. Lack of targeted eating-disorder guidance for counsellors
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review member resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
  Stated by British Association For Counselling And PsychotherapyStated completed
2. Action
  Continue reviewing guidance and resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
  Stated by British Association For Counselling And PsychotherapyStated in progress
3. Action
  Continue highlighting critical professional guidance through member bulletins, publications, the website and member events.
  Stated by British Association For Counselling And PsychotherapyStated in progress
Respondent positions 2
1. Position
  GPs are responsible for maintaining their clinical knowledge, identifying learning needs and adhering to relevant eating disorder guidance.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  As a professional rather than training body, it does not directly deliver specialist training or monitor individual competence in specialist areas.
  Stated by British Association For Counselling And PsychotherapyOutside remit
AI-generated summary

Natalie Melissa Turner · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Natalie Melissa Turner had a long-standing eating disorder and abused laxatives, causing serious illness and repeated hospital admissions. She died at home on 27 October 2020 from the effects of laxative abuse. The concerns included insufficient guidance for GPs managing eating disorder patients who do not engage with treatment, and insufficient guidance for counsellors on when confidentiality should be breached to protect patients at risk of serious harm.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of specific guidance for GPs managing eating disorder patients who are not engaging with treatment
Wider context from the report
“1. The first issue I raise with Parliamentary Under Secretary of State (Minister for Patient Safety and Primary Care), Department of Health & Social Care. • The inquest received some helpful evidence from a GP, Dr ████████, of the Ash Tree House Surgery, Kirkham. In court, I acknowledged the response of that surgery to Natalie’s death which I have found to be thorough, open and constructive, and a genuine attempt to minimise the prospect of a recurrence in the future. Dr ████████ explained that notwithstanding her considerable experience as a GP, General Practitioners do not receive specific guidance in relation to eating disorders, which are often very complex in nature. • It seemed to me that GPs can often find themselves in a difficult position when deciding how to approach dealing with a patient who has an eating disorder, but the situation is all the more challenging when the patient is unwilling to engage with medical professionals and accept treatment which is clearly necessary. Many of these patients ostensibly have capacity to make their own decisions, yet given the nature of their eating disorders may go on to make decisions that are not in their own interests. What the GP can and should do is often unclear. • The number of patients affected is not insignificant: indeed, the inquest heard that this one local surgery had recently identified thirteen of their patients were facing challenges relating to an eating disorder. GPs can resort to the current mental health legislation, MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guidance, and NICE (Eating Disorders Recognition and Treatment) guidance which offers some assistance, but it seems to me that in the absence of guidance which focuses on eating disorder patients and what can be done when a patient is not engaging with treatment, GPs are often left unsure about how to help these patients, and in the absence of some guidance on this issue patients may go without treatment and with potentially fatal consequences. • In response to Natalie’s death, the Lancashire & South Cumbria NHS Foundation Trust has also responded in a constructive manner and have demonstrated a clear plan to avoid a repetition. This response has included the creation of new posts within the Trust who local GPs will be able to access for guidance and these include a Consultant Dietician and a Consultant Nurse, and hopefully local GPs make use of this new assistance, but this is not always the case elsewhere in the country. ”
Source location
Natalie Melissa Turner · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of targeted eating-disorder guidance for counsellors
Wider context from the report
“2. The second issue I raise with the British Association for Counselling and Psychotherapy (BACP): • The inquest heard from a BACP Accredited Counsellor, with whom Natalie shared some 63 counselling privately funded counselling sessions between January and October 2020. • BACP guidance includes a set of core principles which ought to guide counsellors, and the guidance makes clear that in exceptional circumstances the need to safeguard clients from serious harm “may require practitioners to override a commitment to make a client’s wishes and confidentiality the primary concern”. The guidance makes clear that a breach of confidentiality may be justified. • The Counsellor had developed a good therapeutic relationship with Natalie, but in my judgement she felt unduly constrained by the wishing to avoid breaching Natalie’s confidence, despite she herself having formed the view given what Natalie was disclosing to her about the extent of her ongoing laxative abuse she was at risk of self harm and of dying. These circumstances were exceptional, it is hard to think of a clearer example where to disclose her concerns to others would have been justified but she preferred not to because she did not feel she could betray her confidence. This was despite having regular discussions with her supervisor, and knowing that Natalie was not accessing the medical monitoring that she needed from her GP. • The Counsellor explained in court that she personally has not knowingly counselled an eating disorder patient before. The potential complexities of these conditions were not fully appreciated. • Patients with eating disorders will commonly prefer to avoid contact with mainstream medical care and treatment, and their families. It follows that such patients may be attracted to discussing their condition privately with a private counsellor. • Although the therapeutic relationship between counsellor and patient is fundamentally important, as the BCAP guidance makes clear there are occasions when a breach of confidentiality is justifiable. Counsellors who begin a course of therapy with an eating disorder patient need to appreciate that refraining from breaching confidentiality may well mean the patient goes without necessary and potentially life-saving care and treatment. Even if patients try to reassure counsellors that they are seeking medical help elsewhere, such claims may well not be credible because these patients may be claiming they are being treated as a distraction. • The Counsellor informed the court she did not have the benefit of guidance on eating disorders. More information may have highlighted the particular risks eating disorder patients may pose, particular as regards whether to breach confidentiality or not. In the absence of such guidance, I am concerned that there is a risk that vulnerable patients – who may in fact benefit from a disclosure by their counsellor – will miss out on necessary and potentially life – saving treatment. • Whilst acknowledging that on the BACP website [www.bacp.co.uk], within a section headed “Events & resources”, there is a series of articles which explore some of the issues eating disorders may pose for counsellors, the Counsellor who gave evidence at Natalie’s inquest did not appear to be familiar with these articles. This arguably reinforces the need for this subject to be raised with counsellors in a more targeted way. ”
Source location
Natalie Melissa Turner · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review member resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.

Verbatim wording from the response
“In response to your report, we have conducted a thorough review of our member resources relating to confidentiality and when to breach it (including safeguarding and duty of care), working within own limits of competence and guidance on eating disorders specifically.”

Source location
Response from British Association for Counselling and Psychotherapy
Page 1 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue reviewing guidance and resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.

Verbatim wording from the response
“We will continue to keep our guidance and resources under review and to take every opportunity to highlight the critical importance of the professional points and draw them to our members’ attention through our different channels of communication which include”

Source location
Response from British Association for Counselling and Psychotherapy
Page 2 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue highlighting critical professional guidance through member bulletins, publications, the website and member events.

Verbatim wording from the response
“We will continue to keep our guidance and resources under review and to take every opportunity to highlight the critical importance of the professional points and draw them to our members’ attention through our different channels of communication which include”

Source location
Response from British Association for Counselling and Psychotherapy
Page 2 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
GPs are responsible for maintaining their clinical knowledge, identifying learning needs and adhering to relevant eating disorder guidance.

Verbatim wording from the response
“GPs are responsible for ensuring their own clinical knowledge remains up-to-date and for identifying learning needs as part of their continuing professional development. This activity”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 31 March 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
As a professional rather than training body, it does not directly deliver specialist training or monitor individual competence in specialist areas.

Verbatim wording from the response
“As a professional body rather than a training body we can and do offer guidance on specific client issues such as eating disorders and set standards for accredited courses, but we don’t directly deliver the training or monitor individual competence in specialist areas. We are, however, very clear that members should not work outside their limits of competence.”

Source location
Response from British Association for Counselling and Psychotherapy
Page 2 · response
Published 31 March 2022
Open published response
17 Dec2021
Manchester North
Concerns raised1
1. Lack of dissemination and understanding of MARSIPAN guidance among medical professionals
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 14
1. Action
  Support and assure partner-led eating-disorder training and continuing professional development improvements.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Roll out MEED risk assessment and triage guidance and establish whole-system MEED groups with training oversight.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Create shared eating disorder curriculum content across medical Royal Colleges using updated MEED guidance.
  Stated by Academy of Medical Royal CollegesStated in progress
1. Action
  Disseminate revised eating disorder guidance across medical colleges and faculties.
  Stated by Academy of Medical Royal CollegesStated planned
2. Action
  Raise awareness of MARSIPAN guidance through posters, safety flashes, presentations and a formal acute-setting awareness plan.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
3. Action
  Develop and disseminate an acute-hospital eating disorder quick reference guide covering recognition, escalation and specialist contacts.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
4. Action
  Deliver mandatory eating disorder grand rounds and circulate recorded training to relevant clinical staff.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
5. Action
  Update organisational guidance and policies to reflect MEED and roll out the national MEED app across care organisations.
  Stated by Northern Care Alliance NHS Foundation TrustStated in progress
6. Action
  Appoint a consultant psychiatrist and establish standard operating procedures for specialist eating disorder advice.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
7. Action
  Establish a specialist eating disorder advisory network with acute hospitals and partner providers.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progress
8. Action
  Implement MARSIPAN checklists, quick reference guidance and specialist contact arrangements across acute hospitals.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
9. Action
  Develop and disseminate acute-care eating disorder pathways, dietetic and nursing protocols.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
10. Action
  Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
11. Action
  Share case learning through Greater Manchester quality, governance and learning forums.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
Respondent positions 3
1. Position
  The College cannot assure compliance with MARSIPAN guidance because it lacks statutory levers, funding authority and workforce resources.
  Stated by Royal College of PsychiatristsUnable to act
1. Position
  Delivering broader medical training improvements is not within NHS England and Improvement’s remit; HEE, the GMC and partners must lead this work.
  Stated by NHS EnglandOutside remit
2. Position
  The Academy cannot circulate revised guidance directly to individual frontline clinicians because it lacks access to their contact details.
  Stated by Academy of Medical Royal CollegesUnable to act
AI-generated summary

Nichola Jane Lomax · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of dissemination and understanding of MARSIPAN guidance among medical professionals
Wider context from the report
“1) Inadequate Training of doctors and other medical professionals re eating disorders For National / NCA / Royal College of Psychiatrists Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient. Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground. Whilst MARSIPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide. ”
Source location
Nichola Jane Lomax · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Support and assure partner-led eating-disorder training and continuing professional development improvements.

Verbatim wording from the response
“Regarding the matter of concern that you raise related to inadequate training of medical professionals regarding eating disorders - doctors should have the necessary knowledge and experience of mental health to assess patients holistically, considering the individuals’ physical, social and psychological needs. Through the PHSO delivery group, NHSEI is working with HEE and other partners to procure training courses that will increase the capacity of the existing workforce to allow them to provide evidence-based treatment to more people, as they have set out in detail in their responses. The Department will continue to support and assure this work to progress against key actions, including ensuring better awareness of eating disorder training and continuing professional development.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 1 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Roll out MEED risk assessment and triage guidance and establish whole-system MEED groups with training oversight.

Verbatim wording from the response
“There has been a year on year rise in eating disorders and a particular rise through the pandemic across all ages, especially in young people and young adults. Nationally, the law of MEED² in May this year will see the most significant quality improvement in eating disorders in the last 5 years in addition to the transformation of young people’s eating disorder services. This is the “Management of medical emergencies in eating disorders” guidance developed by The Royal College of Psychiatrists (2020) and now embedded in the NICE guidance for eating disorder assessment, treatment and management. This is based on the previous MARSIPAN³ and Junior MARSIPAN guidelines for managing severe anorexia nervosa, but MEED is all ages and all eating disorders with a shared language and risk assessment tool that can be used by all clinical and care professionals across the system.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 3 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Create shared eating disorder curriculum content across medical Royal Colleges using updated MEED guidance.

Verbatim wording from the response
“We are keen to do all we can to improve the training of doctors, as part of wider efforts to ensure such tragic circumstances are not repeated, while acknowledging that medical curricula are already very full, making it challenging to add more content. In order to address this, we have gained a small amount of funding from the GMC to work with all relevant colleges to create a suite of shared curricula content that specialties can tailor to their own needs. The first area being covered is eating disorders.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 18 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate revised eating disorder guidance across medical colleges and faculties.

Verbatim wording from the response
“The updated guidance from the Royal College of Psychiatrists will come to the Academy council (comprising the presidents of all the medical royal colleges) shortly for their cross-specialty support and adoption. The Academy will play its part in ensuring the revised guidance is circulated to all colleges and faculties.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 18 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Raise awareness of MARSIPAN guidance through posters, safety flashes, presentations and a formal acute-setting awareness plan.

Verbatim wording from the response
“The NCA initial investigations highlighted a lack of awareness of MaRSIPAN guidance within the organisation and immediate actions were taken to address this, such as awareness posters, safety flashes and team presentations. Once the Trust investigation was complete, a formal plan to raise awareness of MaRSIPAN guidance and management of eating disorders in the acute setting was developed.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 19 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and disseminate an acute-hospital eating disorder quick reference guide covering recognition, escalation and specialist contacts.

Verbatim wording from the response
“A QRG (Quick Reference Guide) has been developed for Salford, Bury and Oldham which informs all clinical staff of recognition, stratification and actions when a patient with Anorexia Nervosa is admitted to any of our acute hospitals. This also includes guidance on escalation and contact details for referral units in the community and Specialist Eating Disorders at the Priory. It has been disseminated around all staff within the Bury, Oldham, Rochdale and Salford Care Organisations. Why not Rochdale?”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 19 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver mandatory eating disorder grand rounds and circulate recorded training to relevant clinical staff.

Verbatim wording from the response
“Two grand rounds were held at Fairfield General Hospital in November 2021 looking at management of eating disorders in an acute setting. Attendance was mandatory for all medics and as many nurses and advanced health practitioners (which includes dieticians) were asked to attend as possible. The presentation included emphasis on cascading learning to those who were not present. For those unable to attend due to clinical duties or leave, the presentation was recorded and has been circulated to all doctors, senior nurses and advanced health practitioners.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 19 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update organisational guidance and policies to reflect MEED and roll out the national MEED app across care organisations.

Verbatim wording from the response
“A further update on the Trust’s continued action to improve services and addressing your specific areas of concern raised in the Regulation 28 report issued following the inquest was provided on 11 February 2022. Since this time, updated guidance around the recognition and management for Medical Emergencies in Eating Disorders (“MEED”) was released by the Royal College of Psychiatrists in May 2022. This replaces the previous MARSIPAN guidance that was in place at the time of Ms Lomax’s death. The Trust is now taking steps to update all applicable guidance documents and policies to reflect the current MEED guidance. An NCA-wide steering group is in development to agree a NCA level MEED Quick Reference Guide. This will be monitored and progressed through system partners who will discuss and confirm governance arrangements under the Integrated Care System.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 23 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Appoint a consultant psychiatrist and establish standard operating procedures for specialist eating disorder advice.

Verbatim wording from the response
“Specifically, the following actions have now been taken to enable acute care clinicians access to specialist advice:”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 24 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a specialist eating disorder advisory network with acute hospitals and partner providers.

Verbatim wording from the response
“• GMMH are working with colleagues initially at NCA and Priory to establish an effective network or virtual advisory group to then be shared with all acute hospitals with the GMMH footprint to ensure they also have access to specialist advice regarding the implementation of MARSIPAN guidance.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 25 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement MARSIPAN checklists, quick reference guidance and specialist contact arrangements across acute hospitals.

Verbatim wording from the response
“• A MARSIPAN Checklist and Quick Reference Guide to allow for MARSIPAN cases to be identified and management to be followed with contact details for GMMH CEDS are now in place at Emergency Departments and Acute Medical Units across NCA. Information has been disseminated across NCA that GMMH CEDS can provide dietetic advice and general support during office hours and can access support out of hours via the Mental Health Liaison Service. Robust procedures in FGH will include contacting GMMH CEDS within office hours to advise of a MARSIPAN admission, for provision of dietetic advice and discussion of discharge plan/onward referral to Specialist Eating Disorder Unit if indicated. GMMH CEDS will continue to action referrals to Specialist Eating Disorder Units as per the current procedure.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 25 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and disseminate acute-care eating disorder pathways, dietetic and nursing protocols.

Verbatim wording from the response
“• GMMH CEDS are supporting NCA in the development of these pathways to be disseminated across NCA including criteria for access to GMMH and a meeting took place including NCA, Priory and GMMH week commencing 7th February 2022. Part of this work includes GMMH CEDS supporting NCA in the development of dietetic and nursing protocols/MARSIPAN guidance which will be available to acute staff on their intranet.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 25 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.

Verbatim wording from the response
“GMHSCP also acknowledges that the commissioned adult eating disorders service in Bury (like many areas of the country) was insufficient to meet local need. Since then, funding has now also been confirmed between Bury CCG and GMHSCP to implement the GMMH Adult Eating Disorders Business Case.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 39 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share case learning through Greater Manchester quality, governance and learning forums.

Verbatim wording from the response
“Actions taken or being taken to share learning across Greater Manchester.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 41 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The College cannot assure compliance with MARSIPAN guidance because it lacks statutory levers, funding authority and workforce resources.

Verbatim wording from the response
“The College role is one to influence, support and advise, and we do not have any statutory responsibility. For example, in light of the reference to the “MARSIPAN” guidelines in the Report, we have no formal levers by which we can assure ourselves of compliance with it, including the provision of the necessary funding and associated workforce resources to implement it.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 6 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Delivering broader medical training improvements is not within NHS England and Improvement’s remit; HEE, the GMC and partners must lead this work.

Verbatim wording from the response
“This concern also reflects a wider challenge with the levels of training that doctors and other medical professionals receive on mental health. We believe this is imperative to support parity of esteem and improve patient care, particularly for”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 13 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Academy cannot circulate revised guidance directly to individual frontline clinicians because it lacks access to their contact details.

Verbatim wording from the response
“To note, as is reflected in the dissemination plan proposed by the Royal College of Psychiatrists, they will need to work with others in getting it to the frontline, as there is currently no mechanism for them or us to circulate the guidance to individual frontline doctors. We simply do not have the means of contacting individual clinicians who are members of colleges and not of the Academy.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 18 · response
Published 31 December 2021
Open published response
25 Jul2014
Surrey
Concerns raised3
1. Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis
2. Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage
3. Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Revise the eating-disorder triage form to record investigations, physical findings, symptoms, medical history, and potential organic causes.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
2. Action
  Co-author a revised MARSIPAN guideline addressing physical risk monitoring in eating disorders.
  Stated by Royal College of PsychiatristsStated completed
3. Action
  Ask the guideline lead to consider how to disseminate robust eating disorder service proformas across the UK health economy.
  Stated by Royal College of PsychiatristsStated planned
Respondent positions 2
1. Position
  MARSIPAN and its designated expert are responsible for developing and disseminating robust eating disorder risk-assessment proformas and protocols.
  Stated by Royal College of PsychiatristsRedirects responsibility
1. Position
  Advice on concerns relating to hospital medicine should be obtained from hospital medicine rather than the College.
  Stated by Royal College of General PractitionersRedirects responsibility
AI-generated summary

Clare Serena Anke COOPER · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis
Wider context from the report
“8. The lack of a national protocol for assessing patients seriously ill with an eating disorder with the possibility of detecting individuals with an organic basis for the condition. ”
Source location
Clare Serena Anke COOPER · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage
Wider context from the report
“7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service. ”
Source location
Clare Serena Anke COOPER · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes
Wider context from the report
“7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service. ”
Source location
Clare Serena Anke COOPER · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revise the eating-disorder triage form to record investigations, physical findings, symptoms, medical history, and potential organic causes.

Verbatim wording from the response
“We have however reviewed our triage form to ensure that all information including physical investigations is recorded in one form. The changes made include:”

Source location
2014-0345-Response-by-Surrey-Borders-Partnership-NHS
Page 2 · response
Published 25 July 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Co-author a revised MARSIPAN guideline addressing physical risk monitoring in eating disorders.

Verbatim wording from the response
“The specific issue of robust EDS proformas is best tackled through the MARSIPAN Guidelines of the Royal College of Physicians and the Royal College of Psychiatrists, which address physical risk monitoring in eating disorders. I co-authored the original guideline, and have co-authored a revised guideline, but the lead in this has been ████████ whose expertise in risk assessment in eating disorders is well recognised.”

Source location
2014-0345-Response-by-Royal-College-of-Psychiatrist
Page 2 · response
Published 25 July 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ask the guideline lead to consider how to disseminate robust eating disorder service proformas across the UK health economy.

Verbatim wording from the response
“As you will see in my correspondence with the family, I will ask ████████ to consider how best to disseminate robust EDS proformas across the UK health economy, probably best tethered to the next meeting of the revised MARSIPAN Guidelines, which is forthcoming.”

Source location
2014-0345-Response-by-Royal-College-of-Psychiatrist
Page 2 · response
Published 25 July 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
MARSIPAN and its designated expert are responsible for developing and disseminating robust eating disorder risk-assessment proformas and protocols.

Verbatim wording from the response
“The specific issue of robust EDS proformas is best tackled through the MARSIPAN Guidelines of the Royal College of Physicians and the Royal College of Psychiatrists, which address physical risk monitoring in eating disorders. I co-authored the original guideline, and have co-authored a revised guideline, but the lead in this has been ████████ whose expertise in risk assessment in eating disorders is well recognised.”

Source location
2014-0345-Response-by-Royal-College-of-Psychiatrist
Page 2 · response
Published 25 July 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Advice on concerns relating to hospital medicine should be obtained from hospital medicine rather than the College.

Verbatim wording from the response
“I give below detailed comments on the first six matters of concern you list in this particular case, ie those which directly relate to general practitioner care, setting aside your listed concerns 7 to 10 on which advice from hospital medicine will be more appropriate.”

Source location
2014-0345-Response-by-Royal-College-of-General-Practitioners
Page 2 · response
Published 25 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to consider cyclizine addiction in eating disorder services

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Lack of specific guidance for GPs managing eating disorder patients who are not engaging with treatment

Lack of targeted eating-disorder guidance for counsellors

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of dissemination and understanding of MARSIPAN guidance among medical professionals

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.14

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 2

Actions described in response 2

Actions described in response 3

Respondent positions 2

Actions described in response 14

Respondent positions 3