“On a national level there is not a system which is capable of being operated in a way…”

The coroner’s concerns

– (a) On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with T1DE. Specifically, there is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA), an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA. I heard independent evidence from , Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neurosciences at Kings College London that " the lack of a diagnosis for T1DE has an impact because if you don’t know what you are looking for and there aren’t any criteria that you can screen by then it’s very difficult for both patients and clinicians to understand what is wrong with them and this has hampered development of recognition and treatment pathways and building the research evidence". (Copies of s independent expert reports for the Inquest are attached). (b) At a local level in East and North Hertfordshire there is no integrated healthcare system for patients with diabetes and eating disorder as there is in the west of the county. (c) Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison's death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as "private" providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, The Secretary of State for Health and the Officers of the Hertfordshire and West Essex Integrated Care Board have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9th September 2024. I, the coroner, may extend the period.

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, 2024-0373

Added to Minute Book

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