Recurring concern

Insufficient commissioned monitoring for high-risk eating-disorder patients

Pin Get email alerts Request correction

First reported 3 Mar 2021•Latest report 17 Dec 2021

Definition

What this concern includes

Includes failures to establish, commission, clarify, fund or provide monitoring for moderate- or high-risk eating-disorder patients in primary, secondary or community care, including anorexia nervosa and comparable eating-disorder populations.

Not included

  • Excludes general eating-disorder treatment, psychiatric input or service-capacity deficiencies where monitoring provision is not the identified unsafe condition.
  • Excludes generic commissioning, responsibility or communication failures that are not specifically tied to monitoring high-risk eating-disorder patients.
  • Excludes monitoring of low-risk patients or people without an eating-disorder context.
  • Excludes monitoring failures for other named clinical conditions unless the assertion explicitly concerns the same high-risk eating-disorder monitoring provision.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2021–2021

First to latest report issue date

Stated actions
6

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.

Academy of Medical Royal Colleges2
Department of Health and Social Care2
NHS England2
General Medical Council1
Greater Manchester Mental Health NHS Foundation Trust1
NHS Bury Clinical Commissioning Group1
NHS Greater Manchester Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
Priory Group1
Royal College of Psychiatrists1

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.

  1. Manchester North

    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 formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients

    Wider context from the report

    “5) Community Monitoring of patients with an Eating Disorder For BURY CCG / NATIONAL / ICB/ GMHSCP There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate or high risk Eating Disorder patients within the community. The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned. ”

    Source location

    Nichola Jane Lomax · 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

    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

    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

    Priory Hospital Cheadle Royal is not commissioned to provide community interventions, apart from assessments that may lead to admission.

    Verbatim wording from the response

    “1. Accessing Specialist Advice For clarification please note that Priory Hospital Cheadle Royal is commissioned to provide inpatient care and treatment to patients with an eating disorder. The service is not commissioned to provide interventions in the community other than to undertake patient assessments that may or may not result in patient admission.”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 28 · response
    Published 31 December 2021

    Open published response

  2. Cambridgeshire and Peterborough

    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

    Lack of formally commissioned monitoring provision for moderate to high risk Anorexia Nervosa patients

    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 respondent action was interpreted

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

    PFD Monitor interpretation

    Develop physical-health-check training for eating-disorder care with NHS England and NHS Improvement.

    Verbatim wording from the response

    “Further to this, in support of the whole workforce, HEE has developed the ‘Psychological Interventions for People with Eating Disorders: A competence framework in partnership with University College London, which is aimed at all health workers, trainers and supervisors, clinical managers and service commissioners to guide workforce capability development and enhance patient safety. In 2021/22, HEE will be working with NHSE/I to develop physical health check training relating to eating disorder, that is supported by the Physical Health Competency Framework for Mental Health and Learning Disability Settings (HEE December 2020).”

    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

    Share learning from community eating disorder early implementers through the Adult Eating Disorder Clinical Leads forum to support robust medical-monitoring pathways.

    Verbatim wording from the response

    “In 2019/20 and 2020/21, 12 STPs/ICSs were funded to test new models of integrated care, which will include CED. Eight of these sites chose to focus on improvements to CED services as a specialty area. We will ensure that the learning from the community early implementers sites will be shared via the Adult ED Clinical Leads forum to support services as they embed robust medical monitoring pathways.”

    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

    Embed mental health practitioners in Primary Care Networks to improve oversight across primary and secondary care for people with severe mental illness, including eating disorders.

    Verbatim wording from the response

    “In addition, the 2021/22 GP contract and Standard Contract are embedding mental health practitioners in Primary Care Networks (PCNs). Although these practitioners will not directly undertake the medical monitoring themselves, they will be able to liaise with the staff who will undertake it and help to ensure adequate oversight of the care of patients with severe mental illnesses, including eating disorders, across primary and secondary care.”

    Source location

    2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
    Page 3 · response
    Published 8 March 2021

    Open published response
Back to top

Data last updated 7 September 2026