‘Missed opportunities’ led to teenager’s eating disorder death

The 17-year-old was in an “advanced state of starvation” when she died at Northumbria Specialist Emergency Care Hospital in May 2024 – having had no face to face monitoring since November the previous year.

The girl, who had autism, was also not referred to specialist gastroenterology services amidst confusion over referrals between departments by consultants, and died from the effects of “extreme malnourishment”. She weighed less than 32kg.

Northumberland Coroner Andrew Hetherington said he was “concerned there was no physical or face to face monitoring of the deceased’s weight from November 2023," and made recommendations for improvement to Northumbria NHS Healthcare Trust and her GP practice.

He also raised concerns that the girl was discharged by Child and Adolescent Mental Health Services (CAMHS) without being seen in person, spoken to, or weighed. This is despite a consultant's referral highlighting how she should be seen "urgently".

Although her mother warned she may refuse to engage with the service, which resulted in a scheduled appointment being cancelled, the Coroner said there was “no scrutiny” of why this was not the case, or efforts to rectify the situation.

The Coroner also pointed to the situation of referral between consultants, and the fact that by autumn 2023 NHS guidance had changed, so that "consultants could and should" refer patients to other speciality areas themselves if necessary. But this had not been shared with the relevant consultants at this time.

Law firm Slater and Gordon supports families across the country who have suffered harm as a result of poor standards of care.

"This is a devastating case where this young person desperately needed care to support her in managing complex symptoms - but sadly she did not receive the care she so badly required,” says John Lowther, senior associate at Slater and Gordon in Newcastle.

“The fact she was not given face to face support as her illness progressed, and her situation was not escalated, mean there are undoubtedly questions to be answered. 

"People need and deserve the highest standards of bespoke care when they are at their most vulnerable, and again we see the truly tragic consequences of when this does not happen."