First reported 25 Jul 2014•Latest report 7 Jan 2026
Definition
What this concern includes
Includes failures in eating-disorder care pathways to recognise when escalation is required, seek specialist advice, make onward referrals, communicate referral routes or ensure access to appropriate specialist eating-disorder services.
Not included
Excludes generic clinical escalation, referral or communication failures where eating disorder care is not the bounded concern.
Excludes failures in dietetic assessment, weight measurement or telephone consultation where no eating-disorder escalation or referral deficiency is identified.
Excludes treatment, staffing or service-capacity deficiencies after an appropriate eating-disorder escalation or referral has been completed.
Excludes generic mental-health or nutrition-service access problems without a material eating-disorder escalation or specialist-referral connection.
Reports
6
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
36
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care2
NHS England2
Northern Care Alliance NHS Foundation Trust2
Royal College of Psychiatrists2
49 Marine Avenue Surgery1
Academy of Medical Royal Colleges1
Blackpool Council1
Greater Manchester Mental Health NHS Foundation Trust1
Health Centre1
Moorbridge1
NHS Bury Clinical Commissioning Group1
NHS Greater Manchester Integrated Care Board1
NHS North East and North Cumbria Integrated Care Board1
NHS Surrey and Sussex Integrated Care Board1
Northumbria Healthcare NHS Foundation Trust1
NHS trust5
Integrated care board3
Executive non-departmental public body2
Health professional body2
Ministerial department2
Multi-service care provider2
Professional body2
Clinical commissioning group1
English metropolitan district council1
English unitary authority1
Healthcare site1
Independent healthcare provider1
Pupil referral unit / alternative provision1
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.
Black Country
Concerns raised1
Failure to provide onward referral to dieticians experienced in autism and ARFID
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Publish guidance for commissioners and providers on children’s eating disorder services, including ARFID care and reasonable adaptations for additional needs.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Northumberland
Concerns raised1
Failure to escalate care or make onward referral
This report raised 9 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Review internal referral processes to clarify responsibilities and improve timely specialist referrals.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Clarify ambiguous consultant requests and notify consultants when requested actions cannot be completed, seeking further direction where necessary.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Develop and implement eating-disorder management and under-18 safe-management policies covering weight-loss presentations.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Provide staff training on Medical Emergencies in Eating Disorders guidelines, including clinical red flags and escalation pathways.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Implement Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Implement documented clinical supervision for Dietetics staff and Nutrition MDT support, including escalation review for very low BMI patients.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.
Stated by Northumbria Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Introduce a documented SOP for triaging and assessing suspected eating-disorder and disordered-eating referrals.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Embed the MEED assessment tool in outpatient consultation records and direct staff to use MEED and ARFID guidance when assessing patients aged 16 and over.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Overall and specialty-specific outpatient care responsibilities rest with GPs, dieticians, named consultants and care teams, with escalation as needed.
Stated by NHS North East and North Cumbria Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester North
Concerns raised1
Lack of understanding of referral and advice-seeking pathways to the Specialist Eating Disorder Service
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Implement and use a ratified policy defining clinical roles, referral pathways, mandatory specialist-team referrals, and Mental Health Liaison Team responsibilities.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Review and clarify referral policies and procedures for eating-disorder assessments and Mental Health Act considerations.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
Action
Make the referral policy available to staff in both organisations, including Accident and Emergency Department staff.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Share inquest learning and policy details with the appropriate teams through managers.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing policy sufficiently clarifies responsibilities and referral pathways for adult patients with eating disorders across the Trusts.
Stated by Northern Care Alliance NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Blackpool and the Fylde
Concerns raised2
Failure of adult social care staff to recognise concerning signs or deterioration of eating disorders
Lack of access to specialist eating disorder services for people supported by adult social care
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.8
Action
Discuss eating-disorder knowledge and experience with each AMHP in supervision and identify further training needs.
Stated by Blackpool Adult Social ServicesStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.
Action
Request an eating-disorder awareness session for all AMHPs from the specialist eating-disorder service.
Stated by Blackpool Adult Social ServicesStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.
Action
Require social-care staff to access eating-disorder resources and discuss them in supervision, with service-manager confirmation.
Stated by Blackpool Adult Social ServicesStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.
Action
Monitor practitioners supporting people with eating disorders through supervision to assess confidence and further training needs.
Stated by Blackpool Adult Social ServicesStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Action
Provide a suite of eating-disorder resources to all social-work teams through the electronic system.
Stated by Blackpool Adult Social ServicesStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
Action
Develop guidance explaining how staff should respond, act and escalate when a potential eating disorder is identified.
Stated by Blackpool Adult Social ServicesStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Action
Develop a seven-minute eating-disorder briefing for dissemination across Adult Social Care and wider services.
Stated by Blackpool Adult Social ServicesStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Action
Assess whether a specific mental-illness and eating-disorder risk-assessment tool is required.
Stated by Blackpool Adult Social ServicesStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Manchester North
Concerns raised3
Unclear Priory referral and admission criteria for medically stable patients with low BMI
Absence of pathways for acute clinicians to access specialist eating disorder advice
Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
This report raised 13 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
Action
Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Share and consider revised Priory referral criteria with relevant stakeholders.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
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 progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Work with providers to clarify specialist advice and guidance available to acute medical and psychiatric wards.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 December 2021.
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 completedThe respondent said that this action was complete when they made their response on 31 December 2021.
Action
Appoint a consultant psychiatrist and establish standard operating procedures for specialist eating disorder advice.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 December 2021.
Action
Establish a specialist eating disorder advisory network with acute hospitals and partner providers.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Implement MARSIPAN checklists, quick reference guidance and specialist contact arrangements across acute hospitals.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 December 2021.
Action
Develop and disseminate acute-care eating disorder pathways, dietetic and nursing protocols.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 December 2021.
Action
Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.
Stated by NHS Bury Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Develop a community eating disorder medical-monitoring pathway and accept medically stable patients based on clinical assessment rather than BMI alone.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for addressing Priory referral criteria rests with other organisations.
Stated by NHS Bury Clinical Commissioning GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Insufficient communication from referral agents to the eating disorder service
This report raised 13 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Revise the GP referral form to require information supporting assessment and exclusion of organic causes before eating-disorder referral.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 July 2014.
Action
Attach copies of all investigations to every patient referral letter.
Stated by Woodlands SurgeryStated completedThe respondent said that this action was complete when they made their response on 25 July 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
GPs are expected to consider and exclude organic causes before referring patients to the Eating Disorders Service.
Stated by Surrey and Borders Partnership NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in eating-disorder care pathways to recognise when escalation is required, seek specialist advice, make onward referrals, communicate referral routes or ensure access to appropriate specialist eating-disorder services.
