PFD report

Charlotte Lucy Swift · Prevention of Future Deaths report

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Issued 11 May 2021•West Sussex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Unavailability of specialist inpatient eating-disorder beds
    Part of recurring concern: Insufficient specialist support for eating-disorder patients
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Undertake a national inpatient eating-disorder demand and capacity exercise.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
  2. 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 plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
  3. 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 progressThe respondent said that this action was in progress when they made their response on 18 May 2021.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Insufficient specialist support for eating-disorder patients.

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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

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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

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

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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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Deliver a comprehensive eating-disorder training programme with Health Education England, including evidence-based interventions and cognitive behavioural therapy.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
  2. 2

    Appoint regional adult eating-disorder clinical leads across England.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
  3. 3

    Fund 18 eating-disorder services to implement the FREED early-intervention model.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
  4. 4

    Allocate £58 million to support community mental-health services, including accelerated transformation of eating-disorder pathways.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
  5. 5

    Support regional teams and eating-disorder service transformation through specialist expert advice from national clinical and mental-health programme teams.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.

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 comprehensive eating-disorder training programme with Health Education England, including evidence-based interventions and cognitive behavioural therapy.

Verbatim wording from the response

“Training NHSE are also working in partnership with Health Education England (HEE) to deliver a comprehensive training programme to improve the support received by those with eating disorder, including training in cognitive behavioural therapy for eating disorder, and other evidence-based interventions. Around 240 staff (from around 90 teams) have received training in how to better support those with an eating disorder diagnosis and training numbers are set to increase this year.”

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

Appoint regional adult eating-disorder clinical leads across England.

Verbatim wording from the response

“Additionally local plans submitted to NHSE indicate that at least 22 Integrated Care Systems (ICSs) are starting work to transform their community AED pathways in line with published guidance in 2021/22, with over £6m of initial dedicated investment, with remaining ICS localities due to commence in 2022/23 while in 2019/20 and 2020/21, 12 STPs/ICSs “Early Implementers” were funded to test new models of integrated care, including improvements to Community Eating Disorder services. Learnings from these sites will be shared wider with systems and help inform future development and to further support local strategic planning and development of transformed AED pathways in line with published guidance, regional adult eating disorder clinical leads have now been appointed across England.”

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

Fund 18 eating-disorder services to implement the FREED early-intervention model.

Verbatim wording from the response

“Early Intervention Early intervention is critical for those with eating disorders. In 2019/20 NHS England funded 18 eating disorder services to implement the early intervention model - First Episode Rapid Early Intervention for Eating Disorders (FREED), to support the early identification of eating disorders to support young people in the early stages of eating disorders and ensure they can access services sooner. FREED is an evidence-based early-intervention model, for people aged 16-25, presenting with a first episode of eating disorders that has lasted for less than three years. Evidence shows that this model reduces the waiting times for assessment and treatment and that patients experience better outcomes.”

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

Allocate £58 million to support community mental-health services, including accelerated transformation of eating-disorder pathways.

Verbatim wording from the response

“Impact of COVID-19 Pandemic Eating disorder services have been working hard to minimise disruptions in care due to the COVID-19 pandemic by using digital solutions where appropriate, or COVID-safe face-to-face appointments when needed. An additional £58m also has been allocated to support community mental health services responding to COVID, including a focus on accelerating transformation across eating disorder pathways, with a focus on early intervention models and close working with voluntary and community sector partners.”

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

Support regional teams and eating-disorder service transformation through specialist expert advice from national clinical and mental-health programme teams.

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
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026