“Inadequate Training of doctors and other medical professionals re eating disorders For…”

The coroner’s concerns

1) Inadequate Training of doctors and other medical professionals re eating disorders For National / NCA / Royal College of Psychiatrists Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient. Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground. Whilst MARS IPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide. 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. 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 become 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 BMls lower than 14 and have responsibility for the monitoring and co-ordination of the patients care. 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 11 th June. 4) Lack of Critical Services For BURY CCG / ICB /GMHSCP The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital. . The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester. However even though the CEDS is provided by the same mental health trust, it is only the city of Manchester that does have an allocated Consultant Psychiatrist. 5) Community Monitoring of patients with an Eating Disorder For BURY CCG /NATIONAL/ ICB/ GMHSCP There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate to high risk Eating Disorder patients within the community. The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned. 6) Nursing Input and Recording For NCA Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition/ fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect completion of documentation which highlighted her malnutrition but then recorded conflicting information. 7) Delay in Re-Referral For GMMH/PRIORY Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11 th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been remove

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0433

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8 Oct 2026

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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