7 Jan 2026 Joshua Lee Allcock · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1
Failure to provide onward referral to dieticians experienced in autism and ARFID View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Publish guidance for commissioners and providers on children’s eating disorder services, including ARFID care and reasonable adaptations for additional needs.
View source
×
AI-generated summary
Joshua Lee Allcock · 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
Joshua Lee Allcock, a five-year-old boy with complex medical needs and a limited diet, developed severe dehydration after entering foster care and died on 3 January 2023 despite hospital treatment. Concerns included the lack of a formal autism diagnosis and related dietary support, variation in autism assessment practice, and the potential for the capillary refill time test to provide misleading reassurance when assessing dehydration in children with similar circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide onward referral to dieticians experienced in autism and ARFID
Wider context from the report “3. Regrettably, without a formal diagnosis of autism being made, there was no onward referral to dieticians with experience of autism and therefore an understanding of the link between autism and Avoidant restrictive food intake disorder (ARFID) .
” Source location Joshua Lee Allcock · Prevention of Future Deaths report
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 Publish guidance for commissioners and providers on children’s eating disorder services, including ARFID care and reasonable adaptations for additional needs.
Verbatim wording from the response “In January 2026, NHS England published guidance for commissioners and providers on eating disorder services for Children and Young People (CYP) including those with ARFID.” Source location 2026-0012 - Response from NHS England
Open published response
23 Jun 2025 REDACTED Deceased · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 1
Failure to escalate care or make onward referral View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
49 Marine Avenue GP Surgery (NPC Surgery NHS North East and North Cumbria Integrated Care Board Northumbria Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
49 Marine Avenue GP Surgery (NPC Surgery
Review internal referral processes to clarify responsibilities and improve timely specialist referrals.
View source
49 Marine Avenue GP Surgery (NPC Surgery
Clarify ambiguous consultant requests and notify consultants when requested actions cannot be completed, seeking further direction where necessary.
View source
49 Marine Avenue GP Surgery (NPC Surgery
Develop and implement eating-disorder management and under-18 safe-management policies covering weight-loss presentations.
View source
49 Marine Avenue GP Surgery (NPC Surgery
Provide staff training on Medical Emergencies in Eating Disorders guidelines, including clinical red flags and escalation pathways.
View source
Northumbria Healthcare NHS Foundation Trust
Implement Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.
View source
Northumbria Healthcare NHS Foundation Trust
Implement documented clinical supervision for Dietetics staff and Nutrition MDT support, including escalation review for very low BMI patients.
View source
Northumbria Healthcare NHS Foundation Trust
Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.
View source
Northumbria Healthcare NHS Foundation Trust
Introduce a documented SOP for triaging and assessing suspected eating-disorder and disordered-eating referrals.
View source
Northumbria Healthcare NHS Foundation Trust
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.
View source See 6 more actions
×
AI-generated summary
REDACTED Deceased · 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
The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate care or make onward referral
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations.
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral , and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines.
” Source location REDACTED Deceased · Prevention of Future Deaths report
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 internal referral processes to clarify responsibilities and improve timely specialist referrals.
Verbatim wording from the response “We are reviewing internal processes to clarify responsibilities and improve timely referrals for specialist input.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
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 Clarify ambiguous consultant requests and notify consultants when requested actions cannot be completed, seeking further direction where necessary.
Verbatim wording from the response “• Clarification of Referral Pathways: We are fully committed to working with our secondary care colleagues to ensure that any information that is shared between primary and secondary healthcare pathways and communication is implemented as part of the learning and actions from this case. This will be discussed, for action, at the North East and North Cumbria GP Provider interface group by October 2025. If new pathways are introduced, we will seek to confirm they are operational rather than assume everyone is aware. If there is any uncertainty or ambiguity regarding the request in a letter, we will write back to the Consultant to clarify. If any actions are unable to be carried out for any reason, we will write to the Consultant to inform them and ask if any further action on our part is needed.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement eating-disorder management and under-18 safe-management policies covering weight-loss presentations.
Verbatim wording from the response “• New Processes and Policies: We have developed an Eating Disorders Management Standard Operating Procedure (SOP) and a Safe Management of Under-18s with Eating Disorders Policy. These cover the management of patients presenting with weight loss (attached). An initial audit has been undertaken to review all under-18s who have an eating disorder at 49 Marine Avenue Surgery and ensured our management is compliant with the new SOP and policy and that we have a robust review and recall system in place.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
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 Provide staff training on Medical Emergencies in Eating Disorders guidelines, including clinical red flags and escalation pathways.
Verbatim wording from the response “• Training and Awareness: We will provide staff training on the Medical Emergencies in Eating Disorders (MEED) guidelines to increase awareness of clinical red flags and escalation pathways.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
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 Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.
Verbatim wording from the response “2. Internal management re-structure within Dietetics Service to introduce, and empower, a Community Team Lead to oversee and manage all the outpatient work from triage and clinic capacity to reporting, monitoring and planning. This facilitates the provision of alternative outpatient offers, including home visits where concern is raised regarding” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
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 documented clinical supervision for Dietetics staff and Nutrition MDT support, including escalation review for very low BMI patients.
Verbatim wording from the response “4. Introduction of robust, documented clinical supervision was launched formally at the Nutrition and Dietetics Department meeting on 1 April 2025, within the Dietetics staffing structure and also with the Nutrition Team MDT from July 2025.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.
Verbatim wording from the response “5. Development of a Nutrition Multi-disciplinary Team (MDT) meeting which includes medical oversight from Gastroenterologists for complex and vulnerable Dietetic outpatients and mental health oversight from colleagues from the mental health Trust. The first meeting took place on 15 July 2025, scheduled to meet fortnightly and is on track with scheduling. The initial meetings were held with Dietetics and the Trust Gastroenterology consultants to review the current caseloads. Concerns may also be raised to this group outwith the scheduled meetings. This MDT will include mental health colleagues from going forward. The terms of reference are currently being established and will be in place for joint meetings to be scheduled from September 2025.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
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 Introduce a documented SOP for triaging and assessing suspected eating-disorder and disordered-eating referrals.
Verbatim wording from the response “7. The below actions, which had been identified before the Inquest, but were not yet complete, have since been progressed and put in place:” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
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 the MEED assessment tool in outpatient consultation records and direct staff to use MEED and ARFID guidance when assessing patients aged 16 and over.
Verbatim wording from the response “10. Nutrition and Dietetics staff working with patients from 16 years and above, have been advised by the Professional lead for Dietetics, at the monthly Adult team meeting on 25 June 2025, to consider the national MEED guidelines and ARFID (Avoidant/Restrictive Food Intake Disorder) checklist to support the assessment of patients in the out-patient setting for current and future caseloads:” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
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 Overall and specialty-specific outpatient care responsibilities rest with GPs, dieticians, named consultants and care teams, with escalation as needed.
Verbatim wording from the response “Based on the timeline detailed in your report, it appears at the time of ████████ death, she was under the care of the dietician. The GP remains responsible for the overall medical care of the patient, whilst the dietician would manage the specific around the patient's weight. If the dietician had concerns it would be expected that these would be escalated to a senior dietician, the GP, or emergency care services, depending on severity.” Source location 2025-0314 - Response from North East and North Cumbria Integrated Care Board
Open published response
30 Nov 2023 Donna Marie Donnellan · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1
Lack of understanding of referral and advice-seeking pathways to the Specialist Eating Disorder Service View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Northern Care Alliance NHS Foundation Trust Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Northern Care Alliance NHS Foundation Trust
Implement and use a ratified policy defining clinical roles, referral pathways, mandatory specialist-team referrals, and Mental Health Liaison Team responsibilities.
View source
Pennine Care NHS Foundation Trust
Review and clarify referral policies and procedures for eating-disorder assessments and Mental Health Act considerations.
View source
Pennine Care NHS Foundation Trust
Make the referral policy available to staff in both organisations, including Accident and Emergency Department staff.
View source
Pennine Care NHS Foundation Trust
Share inquest learning and policy details with the appropriate teams through managers.
View source See 1 more action
×
AI-generated summary
Donna Marie Donnellan · 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
Donna Marie Donnellan had a long-standing history of disordered eating, severe weight loss and peripheral neuropathy. She was found deceased at home on 10 October 2022, and the investigation recorded death from complications arising from malnutrition likely due to an undiagnosed atypical eating disorder. Concerns included unclear roles between acute clinicians and the Mental Health Liaison Team, and a lack of understanding about referral pathways to specialist eating disorder services.
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 understanding of referral and advice-seeking pathways to the Specialist Eating Disorder Service
Wider context from the report “2) There was a lack of understanding as to the pathways available to the acute clinicians for making a referral/seeking advice from the Specialist Eating Disorder Service ie the Willows.
” Source location Donna Marie Donnellan · Prevention of Future Deaths report
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 and use a ratified policy defining clinical roles, referral pathways, mandatory specialist-team referrals, and Mental Health Liaison Team responsibilities.
Verbatim wording from the response “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.” Source location Response from Northern Care Alliance NHS Foundation Trust
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 and clarify referral policies and procedures for eating-disorder assessments and Mental Health Act considerations.
Verbatim wording from the response “Teams at Pennine Care NHS Foundation Trust have worked closely with colleagues at the Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. We have agreed to jointly review the policy owned by Northern Care Alliance NHS Foundation Trust, Management of Medical Emergencies in Adult Patients with Eating Disorders, which provides clear guidance for staff working within the Accident and Emergency” Source location Response from Pennine Care NHS Foundation Trust
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 Make the referral policy available to staff in both organisations, including Accident and Emergency Department staff.
Verbatim wording from the response “As teams work in partnership to meet the needs of patients within the Accident and Emergency Department, the policy will be available to staff from both organisations. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.” Source location Response from Pennine Care NHS Foundation Trust
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 inquest learning and policy details with the appropriate teams through managers.
Verbatim wording from the response “As teams work in partnership to meet the needs of patients within the Accident and Emergency Department, the policy will be available to staff from both organisations. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.” Source location Response from Pennine Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing policy sufficiently clarifies responsibilities and referral pathways for adult patients with eating disorders across the Trusts.
Verbatim wording from the response “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
9 Oct 2023 Kirandip Bharaj · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2
Failure of adult social care staff to recognise concerning signs or deterioration of eating disorders View source Lack of access to specialist eating disorder services for people supported by adult social care View source
Linked response
Blackpool Adult Social Services
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Blackpool Adult Social Services
Discuss eating-disorder knowledge and experience with each AMHP in supervision and identify further training needs.
View source
Blackpool Adult Social Services
Request an eating-disorder awareness session for all AMHPs from the specialist eating-disorder service.
View source
Blackpool Adult Social Services
Require social-care staff to access eating-disorder resources and discuss them in supervision, with service-manager confirmation.
View source
Blackpool Adult Social Services
Monitor practitioners supporting people with eating disorders through supervision to assess confidence and further training needs.
View source
Blackpool Adult Social Services
Provide a suite of eating-disorder resources to all social-work teams through the electronic system.
View source
Blackpool Adult Social Services
Develop guidance explaining how staff should respond, act and escalate when a potential eating disorder is identified.
View source
Blackpool Adult Social Services
Develop a seven-minute eating-disorder briefing for dissemination across Adult Social Care and wider services.
View source
Blackpool Adult Social Services
Assess whether a specific mental-illness and eating-disorder risk-assessment tool is required.
View source See 5 more actions
×
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 Failure of adult social care staff to recognise concerning signs or deterioration of eating disorders
Wider context from the report “It is important that adult social care staff, should they become aware of concerning signs of a previously unknown eating disorder problem, or identify a possible deterioration in the condition of a service user previously diagnosed with an eating disorder, take action within their range of powers to raise such concerns with the appropriate professionals, and possibly family members.
I have a concern that in the absence of the tools, training and access to the relevant guidance , well - meaning adult social care staff may not recognise when a situation arises and the service user will go without necessary and often very urgent, medical assessment and treatment, and with fatal consequences.
” Source location Kirandip Bharaj · Prevention of Future Deaths report
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 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
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 Discuss eating-disorder knowledge and experience with each AMHP in supervision and identify further training needs.
Verbatim wording from the response “The AMHP lead for Blackpool Council will ensure that all AMHPs within their supervision discuss their knowledge and experience relating to Eating Disorders and will identify if additional specialist training is identified - we will seek to procure this, where required.” Source location Response from Blackpool Council
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 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
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 Require social-care staff to access eating-disorder resources and discuss them in supervision, with service-manager confirmation.
Verbatim wording from the response “We have asked that all Service Managers check and confirm that their staff have accessed and read this information and have a conversation in supervision to explore and discuss further.” Source location Response from Blackpool Council
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 practitioners supporting people with eating disorders through supervision to assess confidence and further training needs.
Verbatim wording from the response “Where we have identified practitioners who are supporting individuals with an eating disorder; we will monitor through supervision, to ensure the worker is sufficiently confident and identify any additional training required - this will be provided.” Source location Response from Blackpool Council
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 Provide a suite of eating-disorder resources to all social-work teams through the electronic system.
Verbatim wording from the response “We have developed a range of resources which are available to all our social work teams; via our electronic system and guidance is being developed which will assist all staff on when a potential eating disorder is identified how they respond, what they need to do and who they need to inform.” Source location Response from Blackpool Council
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 guidance explaining how staff should respond, act and escalate when a potential eating disorder is identified.
Verbatim wording from the response “We have developed a range of resources which are available to all our social work teams; via our electronic system and guidance is being developed which will assist all staff on when a potential eating disorder is identified how they respond, what they need to do and who they need to inform.” Source location Response from Blackpool Council
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 seven-minute eating-disorder briefing for dissemination across Adult Social Care and wider services.
Verbatim wording from the response “• A 7 minute briefing tool is being developed to form part of the suite of resources to assist all staff.” Source location Response from Blackpool Council
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 Assess whether a specific mental-illness and eating-disorder risk-assessment tool is required.
Verbatim wording from the response “• The Service Manager for Adult Mental Health Services is exploring the benefits of a specific risk assessment tool to support social workers in identifying, managing and escalating risk when working with people with a range of mental illness/mental disorders.” Source location Response from Blackpool Council
Open published response
17 Dec 2021 Nichola Jane Lomax · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3
Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Absence of pathways for acute clinicians to access specialist eating disorder advice View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Greater Manchester Mental Health NHS Foundation Trust NHS Bury Clinical Commissioning Group NHS England NHS Greater Manchester Integrated Care Board Northern Care Alliance NHS Foundation Trust Priory Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
Department of Health and Social Care
Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.
View source
Priory Group
Share and consider revised Priory referral criteria with relevant stakeholders.
View source
NHS Greater Manchester Integrated Care Board
Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.
View source
NHS Greater Manchester Integrated Care Board
Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.
View source
NHS England
Work with providers to clarify specialist advice and guidance available to acute medical and psychiatric wards.
View source
Northern Care Alliance NHS Foundation Trust
Develop and disseminate an acute-hospital eating disorder quick reference guide covering recognition, escalation and specialist contacts.
View source
Greater Manchester Mental Health NHS Foundation Trust
Appoint a consultant psychiatrist and establish standard operating procedures for specialist eating disorder advice.
View source
Greater Manchester Mental Health NHS Foundation Trust
Establish a specialist eating disorder advisory network with acute hospitals and partner providers.
View source
Greater Manchester Mental Health NHS Foundation Trust
Implement MARSIPAN checklists, quick reference guidance and specialist contact arrangements across acute hospitals.
View source
Greater Manchester Mental Health NHS Foundation Trust
Develop and disseminate acute-care eating disorder pathways, dietetic and nursing protocols.
View source
NHS Bury Clinical Commissioning Group
Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.
View source
Greater Manchester Mental Health NHS Foundation Trust
Develop a community eating disorder medical-monitoring pathway and accept medically stable patients based on clinical assessment rather than BMI alone.
View source See 9 more actions
×
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 Unclear Priory referral and admission criteria for medically stable patients with low BMI
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
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 Absence of pathways for acute clinicians to access specialist eating disorder advice
Wider context from the report “2) Accessing Specialist Advice
For National, NCA/GMMH/PRIORY
None of the practitioners in Nichola’s case knew how to access specialist eating disorder advice including medical or dietetic advice . There are no pathways to assist acute clinicians in how to access this specialist advice . To this day the clinicians told the Court they would not know where to go other than to try and contact the Priory. The Court heard from the Priory they are not commissioned to provide advice.
” Source location Nichola Jane Lomax · Prevention of Future Deaths report
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 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
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
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 and consider revised Priory referral criteria with relevant stakeholders.
Verbatim wording from the response “2. Referral criteria for the Priory
We have identified referral criteria that we have concluded are accurate for the adult inpatient eating disorder services that Priory Hospital Cheadle Royal provides. It should be noted however that there is always a requirement for some flexibility and proportionality around the criteria given the particular circumstances of each individual patient for example their history, current presentation and any particular current risks that may impact upon their care and treatment. The inclusion and exclusion criteria are as follows:” Source location 2021-0433 - Response regarding Nichola Lomax
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
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
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 providers to clarify specialist advice and guidance available to acute medical and psychiatric wards.
Verbatim wording from the response “In addition, NHS England will work with the Specialised Eating Disorder services in the North West (CWP and The Priory) to clarify the expectation outlined in section 2.5 of the national service specification for Specialised Eating Disorder services around the scope of advice and guidance to acute medical and to psychiatric wards that this should include.” Source location 2021-0433 - Response regarding Nichola Lomax
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and disseminate an acute-hospital eating disorder quick reference guide covering recognition, escalation and specialist contacts.
Verbatim wording from the response “A QRG (Quick Reference Guide) has been developed for Salford, Bury and Oldham which informs all clinical staff of recognition, stratification and actions when a patient with Anorexia Nervosa is admitted to any of our acute hospitals. This also includes guidance on escalation and contact details for referral units in the community and Specialist Eating Disorders at the Priory. It has been disseminated around all staff within the Bury, Oldham, Rochdale and Salford Care Organisations. Why not Rochdale?” Source location 2021-0433 - Response regarding Nichola Lomax
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a consultant psychiatrist and establish standard operating procedures for specialist eating disorder advice.
Verbatim wording from the response “Specifically, the following actions have now been taken to enable acute care clinicians access to specialist advice:” Source location 2021-0433 - Response regarding Nichola Lomax
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a specialist eating disorder advisory network with acute hospitals and partner providers.
Verbatim wording from the response “• GMMH are working with colleagues initially at NCA and Priory to establish an effective network or virtual advisory group to then be shared with all acute hospitals with the GMMH footprint to ensure they also have access to specialist advice regarding the implementation of MARSIPAN guidance.” Source location 2021-0433 - Response regarding Nichola Lomax
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement MARSIPAN checklists, quick reference guidance and specialist contact arrangements across acute hospitals.
Verbatim wording from the response “• A MARSIPAN Checklist and Quick Reference Guide to allow for MARSIPAN cases to be identified and management to be followed with contact details for GMMH CEDS are now in place at Emergency Departments and Acute Medical Units across NCA. Information has been disseminated across NCA that GMMH CEDS can provide dietetic advice and general support during office hours and can access support out of hours via the Mental Health Liaison Service. Robust procedures in FGH will include contacting GMMH CEDS within office hours to advise of a MARSIPAN admission, for provision of dietetic advice and discussion of discharge plan/onward referral to Specialist Eating Disorder Unit if indicated. GMMH CEDS will continue to action referrals to Specialist Eating Disorder Units as per the current procedure.” Source location 2021-0433 - Response regarding Nichola Lomax
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and disseminate acute-care eating disorder pathways, dietetic and nursing protocols.
Verbatim wording from the response “• GMMH CEDS are supporting NCA in the development of these pathways to be disseminated across NCA including criteria for access to GMMH and a meeting took place including NCA, Priory and GMMH week commencing 7th February 2022. Part of this work includes GMMH CEDS supporting NCA in the development of dietetic and nursing protocols/MARSIPAN guidance which will be available to acute staff on their intranet.” Source location 2021-0433 - Response regarding Nichola Lomax
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
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
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
Open published response
25 Jul 2014 Clare Serena Anke COOPER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Insufficient communication from referral agents to the eating disorder service View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Clare Serena Anke COOPER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient communication from referral agents to the eating disorder service
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” Source location Clare Serena Anke COOPER · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the GP referral form to require information supporting assessment and exclusion of organic causes before eating-disorder referral.
Verbatim wording from the response “We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
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 Attach copies of all investigations to every patient referral letter.
Verbatim wording from the response “99% of referrals from Woodlands Surgery go to Surrey and Sussex Healthcare Trust (SASH). The Trust is linked in to the pathology software so for the vast majority of our referrals the hospital does have access to our patients’ pathology results. However from now on all patient referrals will have copies of all investigations (not just blood tests) attached with them to the referral letter.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GPs are expected to consider and exclude organic causes before referring patients to the Eating Disorders Service.
Verbatim wording from the response “We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.