Recurring concern

Failure to reliably report and investigate eating-disorder-related deaths

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First reported 3 Mar 2021•Latest report 17 Dec 2021

Definition

What this concern includes

Includes failures to recognise, refer, investigate or accurately record deaths to which an eating disorder may have contributed, including deaths recorded only by their terminal cause when this obscures the eating-disorder contribution and prevents appropriate coronial investigation or learning.

Not included

Excludes generic failures to report deaths to coroners where an eating-disorder-related death or contribution is not materially identified.
Excludes clinical care, treatment, specialist capacity and mortality-data prevalence concerns where the death-reporting or investigation process is not deficient.
Excludes failures in postmortem examination, evidence preservation or cause-of-death determination unless they directly impair reporting or investigation of an eating-disorder-related death.
Excludes ordinary disagreement with a coroner's properly made decision where the eating-disorder-related death was appropriately reported and investigated.

Reports: 2
Individual concerns: 3
Date range: 2021–2021
Stated actions: 3

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.

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.

17 Dec2021
Manchester North
Concerns raised2
1. Under-reporting of eating disorder deaths to the coroner
2. Lack of appropriate investigation and learning from eating disorder deaths
This report raised 14 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
  Convene a stakeholder round table and publish guidance for medical examiners on investigating eating disorder deaths.
  Stated by NHS EnglandStated planned
2. Action
  Share case learning through Greater Manchester quality, governance and learning forums.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
3. Action
  Monitor key learning and recommendations to ensure they are embedded in practice.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
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
Under-reporting of eating disorder deaths to the coroner
Wider context from the report
“7) Lack of Recognition of the need to Investigate For National Medical Examiner It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder. ”
Source location
Nichola Jane Lomax · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of appropriate investigation and learning from eating disorder deaths
Wider context from the report
“7) Lack of Recognition of the need to Investigate For National Medical Examiner It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder. ”
Source location
Nichola Jane Lomax · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Convene a stakeholder round table and publish guidance for medical examiners on investigating eating disorder deaths.

Verbatim wording from the response
“The National Medical Examiner is also concerned about deaths of people with eating disorders. In late 2021, the National Medical Examiner’s team proposed a round table discussion with subject matter experts and stakeholders, including representatives from the Chief Coroner’s office, with a view to publishing guidance for medical examiners through the National Medical Examiner’s series of Good Practice papers. The round table discussion to inform this paper is due to take place in February 2022, with publication expected later in 2022.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 16 · response
Published 31 December 2021
Open published response
Source evidence

How this respondent action was interpreted

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

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

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

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

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor key learning and recommendations to ensure they are embedded in practice.

Verbatim wording from the response
“In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. GMHSCP is committed to improving outcomes for the population of Greater Manchester.”

Source location
2021-0433 - Response regarding Nichola Lomax
Page 41 · response
Published 31 December 2021
Open published response
3 Mar2021
Cambridgeshire and Peterborough
Concerns raised1
1. Under-reporting and inadequate recording and investigation of eating-disorder-related deaths
This report raised 6 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

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
Under-reporting and inadequate recording and investigation of eating-disorder-related deaths
Wider context from the report
“(3) Lack of robust and reliable data regarding the prevalence of eating disorders Evidence also confirmed that the lack of precise information on the prevalence of eating disorders in the United Kingdom, described by the PHSO Report and the PACAC Follow-up Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” persists. The witness evidence also confirmed the view expressed in the PACAC Report. “This vagueness limits the ability of NHS commissioners to gauge what services need to be provided and encourages them to devote resources to better recorded diseases.” Further, I am concerned that there may also be a significant under-reporting of the extent to which EDs have caused or contributed to deaths, leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’, with only the terminal cause of death, and not the underlying ED cause or contribution to the death, being recorded. In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-estimation of the true mortality rate of EDs. (I propose to explore this issue in separate correspondence with the Medical Examiner for England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ Society of England and Wales). In my view, taken together, the absence of statistically robust data on the numbers of those suffering from EDs and the potential under-estimation of those deaths to which EDs may have caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the future. ”
Source location
Averil Hart · Prevention of Future Deaths report
Page 5 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Under-reporting of eating disorder deaths to the coroner

Lack of appropriate investigation and learning from eating disorder deaths

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

Under-reporting and inadequate recording and investigation of eating-disorder-related deaths

Actions described in response 3