“Evidence at both Averil’s inquest, and those of the women referred to above, established…”

The coroner’s concerns

– Evidence at both Averil’s inquest, and those of the women referred to above, established that a number of the serious matters raised by the Parliamentary Health Service Ombudsman (PHSO) Report ‘Ignoring the alarms: How NHS eating disorder services are failing patients’ published on 8th December 2017 and then reiterated in the ‘Follow-up Report’ to the latter, published by the House of Commons Public Administration and Constitutional Affairs Committee (PACAC) on 18th June 2019, had not been adequately addressed. The Government provided a Response to the recommendations of the PACAC ‘Follow-up Report’ dated 13th August 2019. 3 However, in my view, unless and until the following concerns are appropriately addressed there remains a risk of avoidable future deaths. The specific concerns giving rise to the risk of future deaths are as follows: (1) Inadequate training of doctors and other medical professionals re eating disorders Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all. Evidence at Averil’s inquest (and at those of ) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.” The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths. (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 4 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. (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 Foll

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judiciary.uk, Prevention of Future Deaths reports, 2021-0058

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0