BackA woman died on 15 December 2012, aged only 19, following a series of failures that involved every NHS organisation that should have cared for her. Her family subsequently brought a complaint about her care and treatment to the Ombudsman.
The Ombudsman investigation, led recently by Dr Bill Kirkup, found inadequate coordination and planning of care during a particularly vulnerable time in her life, when she was leaving home to go to university. There were also failures in her care and treatment in two acute trusts when she was seriously ill.
In addition, the local investigation into her death was wholly inadequate with the organisations involved being defensive and protective of themselves, rather than taking responsibility.
Conversations with system leaders and experts in the field suggest there are widespread problems with adult eating disorders services in the NHS. These concerns are reflected in the other casework examples in today’s report:
- A severely ill woman with suicidal thoughts who was inappropriately discharged from hospital with an inadequate care plan in place, died from a heart attack triggered by starvation.
- Another seriously ill woman with a history of vomiting and binge eating died of heart failure after taking an overdose following a catalogue of errors by the NHS, including inconsistent and unhelpful therapy sessions.
Commenting on the investigation, Parliamentary and Health Service Ombudsman Rob Behrens, said: “The tragic death would have been avoided if the NHS had cared for the women appropriately. Sadly, these failures, and her family’s subsequent fight to get answers, are not unique. The families who brought their complaints to us have helped uncover serious issues that require urgent national attention - I hope that our recommendations will mean that no other family will go through the same ordeal.”
Dr Bill Kirkup, said: “Nothing can make up for what happened, but I hope this report will act as a wake-up call to the NHS and health leaders to make urgent improvements to services for eating disorders so that we can avoid similar tragedies in the future.”
The REPORT highlights five areas of focus to improve eating disorder services:
- Training for all junior doctors on eating disorders to improve understanding of these complex mental health conditions;
- Greater provision of eating disorder specialists;
- Adult eating disorder services to achieve parity with child and adolescent services;
- Better coordination of care between NHS organisations treating people with eating disorders;
- National support for local NHS organisations to conduct and learn from serious incident investigations, particularly in circumstances involving several organisations.
The Parliamentary and Health Service Ombudsman is currently developing a new three year strategy, which will see the introduction of new ways of working to resolve cases sooner and improve the overall experience of people making complaints.
Source: Office of the Parliamentary and Health Service Ombudsman, UK
