Clinical Negligence & Catastrophic Injury Solicitors
GPs' knowledge of eating disorders "woeful" says Coroner after student's death
A coroner said GPs' knowledge of eating disorders was "woeful and inadequate" after an inquest into the death of a severely anorexic woman, Madeline Wallace, who died from sepsis.
Coroner, Sean Horstead, told the inquest at Huntingdon Law Courts that "different clinical decisions" would not have prevented her death on January 9 2018 and delivered a narrative conclusion saying Miss Wallace, 18, died of natural causes triggered by severe anorexia.
But Mr Horstead said he would write a Prevention of Future Deaths Report and send it to NHS England chief executive, Sir Simon Stevens, and health secretary, Matt Hancock.
During the inquest, clinical psychologist, Dr Penny Hazel, of Cambridgeshire and Peterborough Foundation Trust (CPFT), said that, while treating Ms Wallace, she "had an awareness" of similar themes between her case and that of Averil Hart, who died in 2012.
Miss Hart, 19, from Newton, Suffolk, died after she experienced rapid weight loss while at university.
A parliamentary health service ombudsman report into her death was being written at the time of Ms Wallace's treatment in 2017 and raised issues, including moving patients from one provider to another, and higher education.
The inquest at Huntingdon Law Courts heard Ms Wallace, a "gifted, highly-intelligent young woman”, was "extremely motivated" about her degree but was concerned about losing weight unless she had help.
Sean Horstead said Ms Wallace also had only one dietician meeting in three months, despite meal preparation and planning being an area of anxiety she had raised.
Dr Hazel said she had tried to make arrangements with the Cullen Centre, Edinburgh, in April 2017 but had been told to call back in August.
The Cullen Centre said it could accept her as a patient only after she registered with a GP and that an appointment could take up to six weeks from then.
Miss Wallace's parents, Christine Reid and Stuart Wallace, said changes were needed to overcome what they called: "NHS staff's limited experience and understanding of anorexia, and poor safety-net systems."
Their statement said: "These need to be implemented as soon as possible to stop any further tragic deaths of young people with everything to live for. There have already been too many such deaths in this region, and elsewhere."
The inquest heard Miss Wallace was the third in a "cluster of deaths" linked to eating disorders.
Mr Horstead said: "A theme that has emerged concerns the adequacy of monitoring high-risk anorexia nervosa suffers."
He said that he remained concerned about what was a national issue and efforts to improve monitoring had been "frustrated by insufficient uptake by GP practices."
He added that coroners had "under-reported" anorexia's direct and indirect contribution to deaths.
Miss Wallace was diagnosed with anorexia nervosa in October 2016 and had "rapidly lost weight" during her first term as a medical student at Edinburgh University in 2017.
She returned home to Peterborough in December 2017 to focus on her recovery.
Mr Horstead said there were "opportunities" in the days before her death to medically assess Miss Wallace and potentially diagnose her infection but, because the infection was the result of her severe anorexia, "different decision making would not have prevented death.”