Recurring concern

Insufficient specialist support for eating-disorder patients

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First reported 13 Feb 2014•Latest report 14 Feb 2024

Definition

What this concern includes

Includes failures in specialist eating-disorder support provision, capacity or access, including sustained supported eating, specialist clinical input and specialist staff availability where these directly affect patients with eating disorders.

Not included

Excludes general mental-health, hospital or social-care capacity deficiencies where eating-disorder specialist support is not the material unsafe condition.
Excludes generic staffing, funding or commissioning failures unless they directly leave eating-disorder patients without required specialist support.
Excludes eating-disorder assessment, referral, monitoring or treatment failures after appropriate specialist support is available, unless the support-provision deficiency is also identified.
Excludes dietetic, psychological or inpatient-bed concerns when they are unrelated to specialist support for eating-disorder patients.

Reports: 8
Individual concerns: 9
Date range: 2014–2024
Stated actions: 26

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 Care4

NHS England4

Academy of Medical Royal Colleges2

NHS Greater Manchester Integrated Care Board2

Blackpool Council1

Cygnet Health Care Limited1

Department for Education1

General Medical Council1

Greater Manchester Mental Health NHS Foundation Trust1

Kent and Medway Mental Health NHS Trust1

National Institute for Health and Care Excellence1

NHS Bury Clinical Commissioning Group1

NHS Norfolk and Suffolk Integrated Care Board1

Norfolk and Suffolk NHS Foundation Trust1

Norfolk County Council1

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. Unavailability of regular dietitian input for children with eating disorders
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 3
1. Action
  Roll out a restricted-eating dietetic referral pathway with parental support tools, professional training and screening through food diaries.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
2. Action
  Review children known to paediatricians to ensure dietetic referrals, appropriate blood tests and access to food supplements.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
3. Action
  Maintain monthly multidisciplinary links between paediatricians and CEDS to discuss concerns and refer children to appropriate ARFID support.
  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
Unavailability of regular dietitian input for children with eating disorders
Wider context from the report
“6. The role of a dietitian in supporting children with eating disorders could be fundamental in maximising the nutritional value of what they consumed. Demands on the service and a limited understanding of how they could work to support children with disorders such as ARFID (nationally) meant that there was rarely regular input from dieticians. ”
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
Roll out a restricted-eating dietetic referral pathway with parental support tools, professional training and screening through food diaries.

Verbatim wording from the response
“• A new dietetic referral pathway for restricted eating which includes a tool to support parents who are concerned. Training of School Nurses and Health Visitors has commenced and will be a rolling program throughout the year to screen when parents raise concerns with 3-day food diaries as part of that pathway.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · 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
Review children known to paediatricians to ensure dietetic referrals, appropriate blood tests and access to food supplements.

Verbatim wording from the response
“Following Alfie’s death, Stockport NHS Foundation Trust has undertaken a review of all children known to paediatricians to ensure all had a referral to dietetics, appropriate blood tests and access to food supplements.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · 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
Maintain monthly multidisciplinary links between paediatricians and CEDS to discuss concerns and refer children to appropriate ARFID support.

Verbatim wording from the response
“Paediatricians and the CEDS continue to link through the monthly multi-disciplinary meetings where they can discuss children, they are worried about, and refer to the CEDS ARFID pathway if appropriate. Although the CEDS ARFID pathway is for children over the age of 8 at the MDT there is the opportunity to discuss children under the age of 8 and CEDS advise on the management.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 22 February 2024
Open published response
9 Oct2023
Blackpool and the Fylde
Concerns raised1
1. Lack of access to specialist eating disorder services for people supported by adult social care
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 1
1. Action
  Request an eating-disorder awareness session for all AMHPs from the specialist eating-disorder service.
  Stated by Blackpool Adult Social ServicesStated planned
AI-generated summary

Kirandip Bharaj · 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

Kirandip Bharaj died aged 45 on 14 September 2019 after sustaining burns and inhaling fumes in an accidental fire at her flat. She had a known eating disorder, declining weight and increasing confusion before her death. The principal concern was that adult social care staff may not recognise deterioration in eating disorders without appropriate tools, training and access to relevant guidance, potentially leaving people without urgent medical assessment and treatment.

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 access to specialist eating disorder services for people supported by adult social care
Wider context from the report
“Many vulnerable people live in the community with support from adult social care, but who may not have access to specialist eating disorder services, perhaps due to a lack of availability or because they are reluctant to engage with specialist services. ”
Source location
Kirandip Bharaj · Prevention of Future Deaths report
Page 4 · 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
Request an eating-disorder awareness session for all AMHPs from the specialist eating-disorder service.

Verbatim wording from the response
“The AMHP lead for Blackpool Council will liaise with LSCFT specialist eating disorder service to formally request they deliver an awareness raising session on what services they provide and how to access eating disorder support – for all AMHPs.”

Source location
Response from Blackpool Council
Page 2 · response
Published 30 October 2023
Open published response
21 Dec2021
Blackpool and the Fylde
Concerns raised1
1. Unavailability of sustained daily supported eating for eating-disorder patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Louise 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

Louise Cooper, who had anorexia nervosa and severe malnourishment, died at home on 16 May 2020 after her health declined. The inquest recorded that she had not received the medical monitoring expected after discharge from an eating disorder service. Concerns included the limited availability of sustained supported eating and whether inadequate monitoring contributed to her death.

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
Unavailability of sustained daily supported eating for eating-disorder patients
Wider context from the report
“• Louise was known to have suffered with anorexia nervosa for many years and during that time her treatment had included a number of in-patient admissions at times when her extremely low weight became concerning. Neither Louise nor her Father felt that these admissions were in fact helping her to improve. • Louise had for some time also received treatment from an eating disorder service. Her treatment had included supported eating whereby once per week a professional would sit with her whilst she ate a meal. She responded positively to this. Indeed, it is of note that when her Father attended our court not long after her death, he commented that had Louise been able to have a professional with her once per day whilst she ate, then the outcome for her may have been different and the costs of providing such a service would have been far less than the significant costs of admitting her for periods of treatment in a hospitals. He described her regular hospital admissions as a “revolving door” which was not helping her. • The Consultant Clinical Psychologist responsible for her care at the eating disorder service had tried to commission an increase in the level of supported eating for Louise but unsuccessfully. She told the court Louise needed this support at least once per day. • There will be many patients such as Louise who appear to make minimal if any improvement in a hospital setting but who may benefit – according to the clinicians treating them – from sustained supported eating. If that option is not available, these patients may be left with no realistic chance of any meaningful improvement. ”
Source location
Louise Cooper · Prevention of Future Deaths report
Page 3 · concerns
Open source report
17 Dec2021
Manchester North
Concerns raised1
1. Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
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 5
1. Action
  Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.
  Stated by Department of Health and Social CareStated in progress
2. 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 progress
3. 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 progress
1. 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 progress
2. 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
Respondent positions 1
1. Position
  Responsibility for addressing Priory referral criteria rests with other organisations.
  Stated by NHS Bury Clinical Commissioning GroupRedirects responsibility
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
Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report
“3) Referral Criteria for the Priory and Community Eating Disorder Service For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care: • As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care. • This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients. The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission. This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June. ”
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
Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.

Verbatim wording from the response
“The traffic light system in MEED has been endorsed by NHSE/I and is being rolled out across the system in Greater Manchester and nationally now so that, like NEWS 2, we can see significant improvement in risk assessment and triage. There will also be a requirement for all ICSs to have a formally established whole-system MEED group, which we have started for young people and are now starting for adults, with a link across the two to ensure the transitions are also addressed. Greater Manchester have also accelerated the review of the whole adult eating disorders pathway, including revised protocols with our independent sector providers and greater collaboration with the voluntary, community and social enterprise sector providing both prevention and recovery support as well as carer support.”

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
Develop a community eating disorder medical-monitoring pathway and accept medically stable patients based on clinical assessment rather than BMI alone.

Verbatim wording from the response
“Greater Manchester Mental Health NHS Foundation Trust (GMMH) welcomes the recent investment by Bury Clinical Commissioning Group (CCG) in the new GMMH clinical model for adult eating disorders which is compliant with national commissioning guidance. This funding commitment will enable the provision of more comprehensive care and treatment to adults with eating disorders under GMMH. This will enable GMMH Community Eating Disorder Services (CEDS) to build on previous advice provided regarding MARSIPAN and dietetic advice for Fairfield General Hospital (FGH) and other acute hospitals across Greater Manchester and to work closely with partner organisations to develop robust pathways to ensure 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
Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.

Verbatim wording from the response
“A business case to expand the service in line with national standards and Greater Manchester and local priorities has been agreed between the CCG and GMMH, and was formally approved by the CCG board on 22 December 2021. I understand that the court was provided with a copy of this business case by GMMH during the course of the inquest; a further copy can be provided if needed. The new model as agreed includes the addition of psychiatry/ medical input to the service (a Consultant Psychiatrist and a Physical Health Practitioner) which will allow patients with a BMI of less than 14 to be accepted by the service and monitored medically by a clinician who has experience and knowledge of eating disorders. In addition it will include:”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 33 · 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
Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.

Verbatim wording from the response
“In advance of this, GMHSCP MH Programme Team are working with partners to ensure the Children and Young Person’s Eating Disorders working group that is already in place is broadened to become an all-age group. This will address wider transition issues between Children’s and Adult Eating Disorder services - an area of particular concern for this patient group. Actions to ensure connectivity of evidence-based pathways that apply consistent referral criteria will be a key part of the work of this group. It will involve clinicians, commissioners, service providers and service users. This is something that has already been encouraged over the past year in the”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 38 · 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 position was interpreted

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

PFD Monitor interpretation
Responsibility for addressing Priory referral criteria rests with other organisations.

Verbatim wording from the response
“The referral criteria for the Priory is best addressed by other organisations but we understand from recent GM meetings that BMI should not be used as a threshold for determining admission as a matter of policy and it is not now relevant in referrals to the CEDS or from there to the Priory.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 34 · response
Published 31 December 2021
Open published response
11 May2021
West Sussex
Concerns raised1
1. Unavailability of specialist inpatient eating-disorder beds
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Implement NHS-led Provider Collaboratives to transform adult and children’s eating-disorder inpatient pathways and develop whole-pathway care models.
  Stated by NHS EnglandStated in progress
2. Action
  Undertake a national inpatient eating-disorder demand and capacity exercise.
  Stated by NHS EnglandStated completed
3. Action
  Use the demand and capacity exercise findings to support reconfiguration of existing eating-disorder beds and development of whole-patient pathways.
  Stated by NHS EnglandStated planned
1. Action
  Work with patient representatives, provider collaboratives, regional colleagues and policy teams to develop new eating-disorder care models addressing capacity and access pressures.
  Stated by NHS EnglandStated in progress
AI-generated summary

Charlotte Lucy Swift · 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

Charlotte Lucy Swift was found unresponsive at her parents’ home on 9 April 2020 and was pronounced deceased at 19.43 hours. She had an eating disorder and urgently needed specialist inpatient treatment, but no bed became available before her death; the report also describes a national shortage of placements and an administrative error that meant she did not receive an expected update from her Consultant.

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
Unavailability of specialist inpatient eating-disorder beds
Wider context from the report
“Charlotte was in urgent need of medical treatment by way of an inpatient bed at a specialist unit for those with eating disorders. Although she had been accepted for such a placement a bed did not become available before she died. Evidence heard at the Inquest indicated that there was a national shortage of placements/beds and this was putting individuals at risk of serious harm and possible death. ”
Source location
Charlotte Lucy Swift · 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
Implement NHS-led Provider Collaboratives to transform adult and children’s eating-disorder inpatient pathways and develop whole-pathway care models.

Verbatim wording from the response
“Specialised Commissioning for inpatient eating disorder beds The high level of demand for access to Specialised Commissioning AED inpatient beds is being addressed through the development of the Provider Collaboratives and new models of care considering the whole patient pathway from Primary Care to Tier 4 national services. The implementation of NHS-Led Provider Collaboratives began in October 2020, with 19 NHS-Led Provider Collaboratives now live and the remaining Phase One Provider Collaboratives being implemented by 1 October 2021.”

Source location
2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
Page 3 · response
Published 18 May 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
Undertake a national inpatient eating-disorder demand and capacity exercise.

Verbatim wording from the response
“The national mental health specialised commissioning team is supporting regional teams and wider eating disorder service transformation through specialist expert advice provided by NHSE Clinical Reference Groups and National Programme of Care for Specialised Mental Health. Additionally, a national inpatient Demand & Capacity exercise has recently been undertaken and findings from this will be used to support the reconfiguration of existing eating disorder beds and the development of whole patient pathways through Provider Collaboratives and ICSs as required by the NHS Long Term Plan.”

Source location
2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
Page 4 · response
Published 18 May 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
Use the demand and capacity exercise findings to support reconfiguration of existing eating-disorder beds and development of whole-patient pathways.

Verbatim wording from the response
“The national mental health specialised commissioning team is supporting regional teams and wider eating disorder service transformation through specialist expert advice provided by NHSE Clinical Reference Groups and National Programme of Care for Specialised Mental Health. Additionally, a national inpatient Demand & Capacity exercise has recently been undertaken and findings from this will be used to support the reconfiguration of existing eating disorder beds and the development of whole patient pathways through Provider Collaboratives and ICSs as required by the NHS Long Term Plan.”

Source location
2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
Page 4 · response
Published 18 May 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
Work with patient representatives, provider collaboratives, regional colleagues and policy teams to develop new eating-disorder care models addressing capacity and access pressures.

Verbatim wording from the response
“Local clinical leaders are working with Patient & Public Voice (PPV) and Expert by Experience (EbyE) representatives, regional colleagues, new provider collaboratives clinical, operational and commissioning leads, alongside NHSE Provider Collaboratives and MH Policy teams to support the development of new care models, to address the significant pressures, capacity and access issues across the system and reduce the reliance on inpatient beds in line with the evidence base for Eating Disorders.”

Source location
2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
Page 4 · response
Published 18 May 2021
Open published response
3 Mar2021
Cambridgeshire and Peterborough
Concerns raised2
1. Unavailability of consultant-level psychiatric input to eating disorder services
2. Shortage of eating disorder specialists
This report raised 5 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 12
1. Action
  Increase psychiatry placements in the Foundation Programme and continue working with the Royal College of Psychiatrists to improve specialty-training fill rates.
  Stated by NHS EnglandStated in progress
2. Action
  Work through a joint eating-disorder expert advisory group to plan future commissioning and determine workforce requirements.
  Stated by NHS EnglandStated in progress
3. Action
  Work with workforce bodies and healthcare providers to identify and implement solutions to the shortage of eating-disorder specialists.
  Stated by General Medical CouncilStated in progress
1. Action
  Expand and train the psychological-therapy workforce, including recruiting practitioners, training existing staff and increasing clinical-psychologist trainees.
  Stated by NHS EnglandStated completed
2. Action
  Map further psychological-therapy and related-role expansion through a workforce plan to guide local workforce planning and education provision.
  Stated by NHS EnglandStated in progress
3. Action
  Commission and deliver whole-team cognitive behavioural therapy training for eating-disorder staff.
  Stated by NHS EnglandStated in progress
4. Action
  Deliver a more integrated primary and secondary care service for people with severe mental illnesses, including eating disorders.
  Stated by Department of Health and Social CareStated planned
5. Action
  Expand and transform mental health services in England, supported by additional annual investment by 2023/24.
  Stated by Department of Health and Social CareStated planned
6. Action
  Allocate £58 million to accelerate integrated primary and secondary community support for adults with severe mental illness, including eating disorders.
  Stated by Department of Health and Social CareStated planned
7. Action
  Work with Health Education England to improve workforce training for adult eating disorder services.
  Stated by NHS EnglandStated in progress
8. Action
  Deliver Cognitive Behavioural Therapy for Eating Disorders postgraduate training for mental health professionals.
  Stated by NHS EnglandStated in progress
9. Action
  Commission a training provider to deliver Maudsley Model of Anorexia Nervosa Therapy for Adults training.
  Stated by NHS EnglandStated planned
Respondent positions 2
1. Position
  Workforce issues, including shortages of eating-disorder specialists, are outside the available powers.
  Stated by General Medical CouncilOutside remit
1. Position
  Responsibility for addressing the shortage of eating disorder specialists rests with the GMC, HEE and the Academy of Medical Royal Colleges.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Averil Hart · 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

Averil Hart died from anorexia nervosa on 15 December 2012, after severe weight loss and deterioration following her discharge from specialist eating-disorder treatment. The report identified concerns about inadequate monitoring and coordination of care, insufficient eating-disorder training and specialist provision, failures to provide nutritional support, delays and miscommunication in hospital care, inadequate data on eating-disorder prevalence and deaths, and the impact of the COVID-19 pandemic.

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
Unavailability of consultant-level psychiatric input to eating disorder services
Wider context from the report
“(2) Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk AN patients by primary or secondary care providers Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) was convened by NHS England (NHSE) to address the specific recommendation for NHSE to review the existing quality and availability of services to achieve parity for adult ED services with children and young people’s ED services. The National Collaborating Centre for Mental Health (NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners and Providers”. However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there remains a lack of formally commissioned provision for the monitoring of AN patients in primary or secondary care across large parts of the United Kingdom. Whilst the evidence received indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop models to ensure the provision of medical monitoring for all ED sufferers, including moderate to high risk patients, there are many areas in the country – including parts of the East of England Region – which still have no such formally commissioned provision. Further, unchallenged evidence identified a number of regions as not even having consultant level psychiatric in-put to the ED services that are purportedly available. There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a number of independent, instructed experts in the fields of ED and AN, that the continued absence of such monitoring and treatment provision gave rise to not only the risk of avoidable future deaths, but - in the views of many - the inevitability of the same. Evidence confirmed that whilst AN has the highest mortality of any mental disorder affecting young people and adults this should not be simply accepted and that AN and other EDs are treatable mental disorders, with even severe complications such as malnutrition safely reversible. The evidence further established that whilst in the long term primary prevention strategies including early recognition and treatment of the disease was critical, in the short to medium term, improving access to treatment and the effective monitoring of the severely ill is to be regarded as essential to address the risk of avoidable future deaths. ”
Source location
Averil Hart · Prevention of Future Deaths report
Page 4 · 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
Shortage of eating disorder specialists
Wider context from the report
“(1) Inadequate training of doctors and other medical professionals re eating disorders Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all. Evidence at Averil’s inquest (and at those of ████████) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.” The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths. ”
Source location
Averil Hart · Prevention of Future Deaths report
Page 4 · 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
Increase psychiatry placements in the Foundation Programme and continue working with the Royal College of Psychiatrists to improve specialty-training fill rates.

Verbatim wording from the response
“As set out in Stepping forward to 2020/21: The Mental Health Workforce Plan for England, published in July 2017, HEE is working with the Royal College of Psychiatrists (RCPsych) to address the fill rates in psychiatry specialty training. Part of this work has resulted in an increase in the number of doctors in the Foundation Programme working in a four-month psychiatry post to 47% nationally in 2018, and HEE continues to work with the RCPsych to improve on this.”

Source location
2021-0058-Response-from-Health-Education-England-Redacted
Page 2 · response
Published 8 March 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
Work through a joint eating-disorder expert advisory group to plan future commissioning and determine workforce requirements.

Verbatim wording from the response
“HEE is currently working with NHSE/I within a joint eating disorder expert advisory group to ensure effective planning for future commissioning activities and determine the workforce requirements of eating disorder services across the demographic. This work will include the urgent development of an education and training commissioning framework agreement.”

Source location
2021-0058-Response-from-Health-Education-England-Redacted
Page 3 · response
Published 8 March 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
Work with workforce bodies and healthcare providers to identify and implement solutions to the shortage of eating-disorder specialists.

Verbatim wording from the response
“The final point you raise as part of the first concern is that there is a serious shortage of ED specialists. We’ve heard evidence of a continuing shortage of ED specialists across the country, with many trusts finding it difficult to fill vacancies. These shortages inevitably impact on the level and quality of support available to primary care providers and other specialists. Your report evidences this staffing crisis, whereby heavy workloads with insufficient staffing compounded failings in Averil’s care. Although workforce issues are not specifically within our powers, we are working with the workforce bodies and health care providers across the UK to identify and implement solutions.”

Source location
2021-0058-Response-from-General-Medical-Council-Redacted
Page 4 · response
Published 8 March 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
Expand and train the psychological-therapy workforce, including recruiting practitioners, training existing staff and increasing clinical-psychologist trainees.

Verbatim wording from the response
“growth targets, education programmes are being commissioned to upskill the existing workforce working with children and adults in psychological therapies and eating disorder treatments. This training is provided across the whole of the mental health workforce ranging from specialist practitioners such as in CBT in eating disorders, teams via Whole Team Training and general awareness such as upskilling junior doctors and nurses.”

Source location
2021-0058-Response-from-Health-Education-England-Redacted
Page 3 · response
Published 8 March 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
Map further psychological-therapy and related-role expansion through a workforce plan to guide local workforce planning and education provision.

Verbatim wording from the response
“Many of the expanded workforce will be delivering psychological interventions for people with an eating disorder, the growth of which has been complemented by the HEE provision of 4,500 adult Improving Access to Psychological Therapies practitioners. For children and young people we have recruited 700 new practitioners and trained 3,400 existing NHS staff between 2016 and 2021. HEE has also increased the number of clinical psychologists in training by 25% in 20/21 and 21/22. A psychological professions workforce plan is in train which will map the further expansion of, psychological therapies and related roles to guide local workforce planning and education provision.”

Source location
2021-0058-Response-from-Health-Education-England-Redacted
Page 3 · response
Published 8 March 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
Commission and deliver whole-team cognitive behavioural therapy training for eating-disorder staff.

Verbatim wording from the response
“The additional commissions we subsequently made included Cognitive Behaviour Therapy specifically for eating disorders, delivered via whole team training from late 2020. This training covers the whole range of expertise, including ED specialists (70 trained) as well as other staff delivering care in eating disorders services (270 trained to date).”

Source location
2021-0058-Response-from-Health-Education-England-Redacted
Page 3 · response
Published 8 March 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 a more integrated primary and secondary care service for people with severe mental illnesses, including eating disorders.

Verbatim wording from the response
“Under the NHS Long Term Plan, we are committed to ensuring a more integrated service across primary and secondary care for people with severe mental illnesses, including eating disorders, and to giving 370,000 adults with severe mental illness greater choice and control over their care and support to live well in their communities by 2023/24. To support improvements in mental health care more generally, including eating disorder care, we remain committed to expanding and transforming mental health services in England and to investing an additional £2.3 billion a year in mental health services by 2023/24.”

Source location
2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Page 2 · response
Published 8 March 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
Expand and transform mental health services in England, supported by additional annual investment by 2023/24.

Verbatim wording from the response
“Under the NHS Long Term Plan, we are committed to ensuring a more integrated service across primary and secondary care for people with severe mental illnesses, including eating disorders, and to giving 370,000 adults with severe mental illness greater choice and control over their care and support to live well in their communities by 2023/24. To support improvements in mental health care more generally, including eating disorder care, we remain committed to expanding and transforming mental health services in England and to investing an additional £2.3 billion a year in mental health services by 2023/24.”

Source location
2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Page 2 · response
Published 8 March 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
Allocate £58 million to accelerate integrated primary and secondary community support for adults with severe mental illness, including eating disorders.

Verbatim wording from the response
“As part of the Government’s commitment to build back better post-COVID, on 27 March we published our Mental Health Recovery Action Plan⁴, backed by an additional £500 million of targeted investment, to ensure that we have the right support in place over the coming year.”

Source location
2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Page 3 · response
Published 8 March 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
Work with Health Education England to improve workforce training for adult eating disorder services.

Verbatim wording from the response
“NHSEI are working with Health Education England (HEE) to improve workforce training for the adult eating disorder workforce. This is in line with NHS Long Term Plan commitments and backed by significant investment (funding in place up to 2023/24).”

Source location
2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 3 · response
Published 8 March 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 Cognitive Behavioural Therapy for Eating Disorders postgraduate training for mental health professionals.

Verbatim wording from the response
“The training courses that are being offered / developed include:”

Source location
2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 3 · response
Published 8 March 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
Commission a training provider to deliver Maudsley Model of Anorexia Nervosa Therapy for Adults training.

Verbatim wording from the response
“• Maudsley Model of Anorexia Nervosa Therapy for Adults (MANTRA): MANTRA is a cognitive-interpersonal treatment. This course is aimed at experienced mental health professionals, to provide them with the skills necessary to deliver this evidence based and NICE recommended treatment. A training provider will be commissioned to deliver this course in 2021/22.”

Source location
2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 4 · response
Published 8 March 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
Workforce issues, including shortages of eating-disorder specialists, are outside the available powers.

Verbatim wording from the response
“The final point you raise as part of the first concern is that there is a serious shortage of ED specialists. We’ve heard evidence of a continuing shortage of ED specialists across the country, with many trusts finding it difficult to fill vacancies. These shortages inevitably impact on the level and quality of support available to primary care providers and other specialists. Your report evidences this staffing crisis, whereby heavy workloads with insufficient staffing compounded failings in Averil’s care. Although workforce issues are not specifically within our powers, we are working with the workforce bodies and health care providers across the UK to identify and implement solutions.”

Source location
2021-0058-Response-from-General-Medical-Council-Redacted
Page 4 · response
Published 8 March 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
Responsibility for addressing the shortage of eating disorder specialists rests with the GMC, HEE and the Academy of Medical Royal Colleges.

Verbatim wording from the response
“In relation to the training of medical professionals in eating disorders, we agree that doctors should have the necessary knowledge and experience 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. I share your concerns on the shortage of eating disorder specialists across the country. I understand that colleagues in the GMC, HEE and the Academy of Medical Royal Colleges will also address this in their responses.”

Source location
2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Page 2 · response
Published 8 March 2021
Open published response
17 Sep2019
Norfolk
Concerns raised1
1. Delays in Eating Disorder Service assessment due to caseload capacity
This report raised 2 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 1
1. Action
  Implement cross-team joint working, risk-prioritised access, escalation of capacity concerns, and coordinated reviews for service users with complex co-morbid conditions.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Most specific recommendations concern health partners, which will provide the Coroner with a joint response on matters pertinent to them.
  Stated by Norfolk County CouncilRedirects responsibility
AI-generated summary

Tyla Katherine Joan COOK · 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

Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.

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
Delays in Eating Disorder Service assessment due to caseload capacity
Wider context from the report
“1. It was agreed at the CETR meeting on 9 August 2017 that Tyla was to be seen by the Eating Disorder Service. He was not seen until 25 October 2017. The evidence was the 11 week delay in seeing Tyla was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with Tyla; ”
Source location
Tyla Katherine Joan COOK · 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
Implement cross-team joint working, risk-prioritised access, escalation of capacity concerns, and coordinated reviews for service users with complex co-morbid conditions.

Verbatim wording from the response
“Trust response to concern 1: In order to prevent delays accessing care when a service user presents with complex co-morbid mental health conditions the following process has been developed.”

Source location
2019-0299-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 1 November 2019
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
Most specific recommendations concern health partners, which will provide the Coroner with a joint response on matters pertinent to them.

Verbatim wording from the response
“The majority of the specific points made in your report relate to actions to be taken by our health partners. We have been in liaison with health colleagues on these matters and the various health partnerships will be providing you with their joint response to the recommendations pertinent to them.”

Source location
2019-0299-Response-by-Norfolk-County-Council_Redacted
Page 2 · response
Published 1 November 2019
Open published response
13 Feb2014
Inner West London
Concerns raised1
1. Lack of local inpatient specialist eating disorder beds
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Lisa Marie Inkin · 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

Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.

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 local inpatient specialist eating disorder beds
Wider context from the report
“2. The complete lack of any local in-patient specialist eating disorder beds. ”
Source location
Lisa Marie Inkin · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Unavailability of regular dietitian input for children with eating disorders

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

Concerns raised1

Lack of access to specialist eating disorder services for people supported by adult social care

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

Concerns raised1

Unavailability of sustained daily supported eating for eating-disorder patients

Concerns raised1

Exclusion of patients with BMI below 14 from the Community Eating Disorder Service

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Unavailability of specialist inpatient eating-disorder beds

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

Concerns raised2

Unavailability of consultant-level psychiatric input to eating disorder services

Shortage of eating disorder specialists

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

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

Actions described in response 3

Actions described in response 1

Actions described in response 5

Respondent positions 1

Actions described in response 4

Actions described in response 12

Respondent positions 2