Averil Hart

Date of report	3 Mar 2021
Reference	2021-0058
Deceased	Averil Hart
Coroner	Sean Horstead
Coroner area	Cambridgeshire and Peterborough
Category	Hospital Death (Clinical Procedures and medical management) related deaths
Source	judiciary.uk record · original PDF
Responses published	4

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

THIS REPORT IS BEING SENT TO: 

1.  The Right Honourable Matt Hancock, Secretary of State for Health and Social Care 

2. 

3. 

4. 

5. 

, Chief Executive of the NHS; 

, Medical Director and Director of Education Standards, General Medical 

Council; 

, Chief Executive of the Academy of Medical Royal Colleges; 

 Chief Executive of Health Education England 

1 

CORONER 

I am Sean Horstead, Assistant Coroner, for the Coroner area of  Cambridgeshire & Peterborough 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009   and Regulations 
28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On 23rd January 2018 I commenced an investigation into the death of Averil Miranda Hart, aged 
19 years. The investigation concluded at the end of the inquest on 6th November 2020. The 
medical cause of death was confirmed as 1a Anorexia Nervosa; I recorded a narrative conclusion 
that the death was avoidable and that it was contributed to by neglect.  I identified the following 
systemic and individual failings: 

(1)  The lack of a formally commissioned service for the provision of medical monitoring of             an 

Anorexia Nervosa (AN) patient at high risk of relapse and, in this lacunae, the absence of      a 
written service level agreement between primary and secondary care, led to confusion as to 
precisely how the two services were to work together. This systemic failure contributed 
significantly to the lack of clear two-way communication between the GP practice at the UEA 
Medical Centre and the Norfolk Community Eating Disorder Service (NCEDS), which in turn 
impacted upon the assessment and management of, and response to, Averil’s risk of relapse. 

(2)  In the context of a severe staffing crisis, the inappropriate allocation by NCEDS of an AN patient at 
a high risk of relapse to the case load of an inexperienced trainee psychologist designated the 
dual roles of therapist and Care Coordinator, but for whom inadequate training and insufficient 
supervision for the latter role was provided, in turn compounded by a lack of proactive support 
from the wider NCEDS team leading to significant shortcomings in the coordination of Averil’s 
case. 

(3)  The failure of the NCEDS team to speak directly with Averil’s father following his raising        of grave 

concerns regarding his daughter’s serious deterioration (over a week prior to     her collapse) to obtain 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 details of his concerns, leading to a missed opportunity to arrange           an urgent medical review of 
Averil and, on balance, avoid the subsequent collapse and emergency admission to hospital; 

(4)  The failure to adequately plan for or provide any nutritional support to Averil over the course of four 
days at North Norfolk University Hospital (NNUH), in the context of her severely malnourished 
condition (recognised on admission), directly contributed to Averil’s death and was a gross failure 
amounting to neglect.  

(5)  Inadequacies in the commissioned structure at NNUH resulted in the absence of weekend support 

from both a consultant psychiatrist fully conversant with eating disorders and a dietician trained to 
provide AN dietetic support as required by the MARSIPAN Guidance. In the context of the lack of 
any nutritional support, the failure by staff to recognise and manage       Averil’s Anorexic behaviours 
whilst on the Acute Medical Unit contributed to her continued deterioration which in turn led to her 
emergency transfer to Addenbrookes Hospital (AH). 

(6)  An unexplained four-hour delay before the consultant gastroenterologist was informed following 
her arrival at AH was compounded by the eight hour delay in Averil being clerked by a junior 
doctor and her bloods being taken.  This led to a missed opportunities to (a) start nasogastric 
feeding on the          afternoon of her arrival; and (b) rapidly identify and treat her hypoglycaemia which 
was left untreated overnight 

(7)  These missed opportunities were compounded by miscommunication over the telephone in the 
early hours of the following morning             between the junior doctor on the ward and the responsible 
consultant with respect to   the recognition of Averil’s (continuing) hypoglycaemia and treatment 
thereof. However, given the already greatly diminished chances of survival Averil faced following 
her period at NNUH prior to her arrival at AH, it could only be safely concluded that the identified 
failings in care at AH possibly contributed to her death. 

4 

CIRCUMSTANCES OF THE DEATH 

On 15th December 2012 Averil died from Anorexia Nervosa at Addenbrookes Hospital, 
Cambridgeshire 6 days short of her twentieth birthday. On 3rd August, Averil had been discharged 
from Ward S3, the Specialist Eating Disorder Unit, run by Cambridgeshire & Peterborough NHS 
Foundation Trust (CPFT), based at Addenbrookes Hospital.  She had received 11 months’ 
treatment   for the AN from which she had been suffering for some three years prior to her 
admission. At discharge her weight had increased from 30.4 kg (with a BMI of 11.2) on admission 
to 45.2 kg (a BMI of 16.6). 

Averil had accepted an offer of a place to study at the University of East Anglia and moved in to 
University halls of residence in September 2012. GPs at the UEA Medical Centre, where she 
registered on 29th September, agreed to provide Averil with medical monitoring on a weekly basis. 
From mid-October Averil also received therapeutic counselling (Cognitive Behavioural Therapy) 
from  a trainee clinical psychologist at the Norfolk Community Eating Disorder Service (NCEDS – 
also run by CPFT) during  the course of which it was decided that Averil was to be weighed by the 
therapist (rather than the UEAMC GPs) on a weekly basis. Averil was last weighed at NCEDs on 
23rd November, after which her therapist was on leave for a fortnight.  Her weight was recorded on 
that occasion as 38.2 kgs, with a BMI of 14. 

On the 28th November, having met up with his daughter earlier that day for the first time in a month, 
Averil’s father had contacted Ward S3 to raise his grave concerns regarding Averil’s apparent 
physical and mental presentation which he considered had dramatically deteriorated.  He told the 
recipient of the call that, in his opinion, her BMI appeared to be lower than when she had been 
admitted to hospital the previous year. 
 was later informed that the NCEDS team had been 
made aware of his concerns. Averil’s scheduled therapy session for the 30th November, where her 
weight would have been taken, did not take place as her therapist was on leave. Alternative 

2 

 
 
 
 
 
 
 
 
 
 arrangements for another member of the team to review Averil and her weight had not been made. 

On Friday 30th November the Lead Consultant Psychiatrist for NCEDS, having been alerted to 

 concerns about his daughter’s weight loss, reviewed the NCEDS records relating to Averil   
and concluded that a medical review should be undertaken by a fellow consultant psychiatrist.  He 
emailed his colleague to this effect the same day and a medical review was subsequently arranged 

th December, some nine days after the concern raised by 

for Friday 7
6th December Averil cancelled the appointment. 

. On the evening of the 

The following morning she was found in a collapsed state in her University accommodation and was 
taken to Norfolk and Norwich University Hospital (NNUH) by ambulance. On admission her weight 
was recorded as 30.7 kg with a BMI of 11.3: her over-all weight loss in four months since discharge 
from Ward S3 was therefore some 14.5 kg, a third of her body weight. 

Although Averil was assessed by clinicians at NNUH, including a Consultant Gastroenterologist 
(who was also the Lead in Nutrition) and recognised to be severely malnourished, over the course 
of her four-day admission      she received no monitored oral nutrition and nor did she receive feeding 
via a nasogastric tube; in addition, her continuing Anorexia driven, energy-expending behaviours 
were not addressed. Averil’s condition continued to deteriorate and by the morning of Tuesday 11th 
December she was struggling to swallow; an emergency transfer by ambulance with blue lights and 
siren for specialist care at Addenbrookes Hospital was arranged. 

Despite the urgency of the transfer, Averil was not reviewed by the specialist medical    team at AH, 
led by a Consultant Gastroenterologist, until around 19.00 hours, approaching five hours after her 
arrival; Averil was only formally clerked in by a junior doctor (and her bloods taken for analysis) 
sometime after 22.30 hours that evening. Overnight her finger prick blood sugar level was 
“unrecordable” and once the results of her blood test were received in the early hours of the 
morning, these confirmed that her laboratory serum glucose was 1.9 mmols/l. 

Notwithstanding the written instructions of the Consultant that Averil’s blood sugar levels should be 
carefully monitored overnight and that she should receive oral glucose should her BM  fall below 3 
mmols/l (and following a miscommunication during a telephone call between the consultant and the 
junior doctor on the ward) Averil’s hypoglycaemia remained entirely untreated. On the morning of 
the 12th December the Consultant visited Averil and found her in a state of collapse. She was 
treated with intravenous dextrose, oxygen and nasogastric feeding but she further deteriorated, did 
not regain consciousness and passed away on the 15th December. 

5 

 CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. A number of the 
concerns raised by the evidence at Averil’s inquest, were also reflected in the evidence I received at 
the separate inquests of four further women in the year preceding Averil’s inquest, namely the inquests 
of 
(died 20/08/2018) and 
identified as the medical cause of death; to a significant degree, the five inquests shared common 
themes of concern. In          my opinion there is a risk that future deaths could occur unless action is taken. 
In the circumstances it is my statutory duty to report to you. 

 (died 22/08/2018). For all of these women Anorexia Nervosa was 

(found deceased 07/09/2017); 

 died (09/01/2018); 

The MATTERS OF CONCERN are as follows.  – 

Evidence at both Averil’s inquest, and those of the women referred to above, established that a number 
of the serious matters raised by the Parliamentary Health Service Ombudsman (PHSO) Report ‘Ignoring 
the alarms: How NHS eating disorder services are failing patients’ published on 8th December 2017 and 
then reiterated in the ‘Follow-up Report’ to the latter, published by the House of Commons Public 
Administration and Constitutional Affairs Committee (PACAC) on 18th June 2019, had not been 
adequately addressed. The Government provided a Response to the recommendations of the PACAC 
‘Follow-up Report’ dated 13th August 2019. 
3 

 
 
 
 
 
 
 
 
 
 
 
 However, in my view, unless and until the following concerns are appropriately addressed there remains 
a risk of avoidable future deaths.  The specific concerns giving rise to the risk of future deaths are as 
follows: 

(1)  Inadequate training of doctors and other medical professionals re eating disorders 

Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the 
evidence of clinicians attending the four inquests of the women referred to above.  All five 
inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or 
experience on the part of physicians and medical staff (including GPs and nurse practitioners, as 
well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and 
specifically Anorexia Nervosa (AN).  Many witnesses (from both the death 2012 and those in 
2017/2018) conceded that they had had only the most superficial knowledge of the often 
complex issues relating to recognition, monitoring, management and treatment of EDs and AN 
specifically.  Their evidence often reflected a lack of familiarity with the King’s College Guidance 
for the treatment of AN in the community.  The evidence of hospital staff revealed, at best, 
inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the 
emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all. 

Evidence at Averil’s inquest (and at those of 
limited progress has been made in respect of the PHSO recommendation with regard to the 
training of doctors and other medical professionals, (notwithstanding the further 
recommendations of the PACAC Follow-up Report and the Government Response to the latter’s 
Recommendations).  These concerns have been reiterated by the Position Statement of the 
Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and 
competence in risk assessment and management of people with eating disorders: What all 
doctors need to know.” 

) suggested that 

The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute 
medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there 
was in 2012, a continuing and serious shortage of eating disorder specialists across the country 
with many Trusts finding it difficult to fill vacancies; such shortages inevitably impact upon the 
level and quality of support available to primary care providers and other specialists and 
therefore, in my view, risks avoidable future deaths. 

(2)  Lack of formally commissioned service level agreement for the provision of robust and effective 

monitoring of moderate to high risk AN patients by primary or secondary care providers 

Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) 
was convened by NHS England (NHSE) to address the specific recommendation for NHSE to 
review the existing quality and availability of services to achieve parity for adult ED services with 
children and young people’s ED services.  The National Collaborating Centre for Mental Health 
(NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating 
Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners 
and Providers”. 

However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there 
remains a lack of formally commissioned provision for the monitoring of AN patients in primary or 
secondary care across large parts of the United Kingdom.  Whilst the evidence received 
indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop 
models to ensure the provision of medical monitoring for all ED sufferers, including moderate to 
high risk patients, there are many areas in the country – including parts of the East of England 
Region – which still have no such formally commissioned provision.  Further, unchallenged 
evidence identified a number of regions as not even having consultant level psychiatric in-put to 
the ED services that are purportedly available. 

There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a 
number of independent, instructed experts in the fields of ED and AN, that the continued 
absence of such monitoring and treatment provision gave rise to not only the risk of avoidable 
future deaths, but - in the views of many - the inevitability of the same.  Evidence confirmed that 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 whilst AN has the highest mortality of any mental disorder affecting young people and adults this 
should not be simply accepted and that AN and other EDs are treatable mental disorders, with 
even severe complications such as malnutrition safely reversible.  The evidence further 
established that whilst in the long term primary prevention strategies including early recognition 
and treatment of the disease was critical, in the short to medium term, improving access to  

treatment and the effective monitoring of the severely ill is to be regarded as essential to address 
the risk of avoidable future deaths. 

(3)  Lack of robust and reliable data regarding the prevalence of eating disorders 

Evidence also confirmed that the lack of precise information on the prevalence of eating 
disorders in the United Kingdom, described by the PHSO Report and the PACAC Follow-up 
Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating 
disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” 
persists.  The witness evidence also confirmed the view expressed in the PACAC Report: “This 
vagueness limits the ability of NHS commissioners to gauge what services need to be provided 
and encourages them to devote resources to better recorded diseases.” 

Further, I am concerned that there may also be a significant under-reporting of the extent to 
which EDs have caused or contributed to deaths, leading to cases either not being referred to the 
coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’ 
with only the terminal cause of death, and not the underlying ED cause or contribution to the 
death, being recorded.  In such circumstances there is a concern that a number of such deaths 
(where, for example, lack of care may have contributed to the death) are neither investigated 
appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-
estimation of the true mortality rate of EDs.   

(I propose to explore this issue in separate correspondence with the Medical Examiner for 
England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ 
Society of England and Wales). 

In my view, taken together, the absence of statistically robust data on the numbers of those 
suffering from EDs and the potential under-estimation of those deaths to which EDs may have 
caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the 
future. 

(4)  The impact of the COVID 19 pandemic 

I am concerned that the matters giving rise to the risk of future deaths identified at points (1) to 
(3) above have been - and will continue to be - significantly exacerbated by the on-going 
pandemic.  I therefore request that responses to the above recognise and expressly address this 
concern. 

6 

 ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you  and your 
organisation(s) 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 
Wednesday 28th April 2021. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out      the timetable for 
action. Otherwise you must explain why no action is proposed. 

8 

 COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:  

•  The family of Averil Hart; 
•  Cambridgeshire & Peterborough NHS Foundation Trust (CPFT); 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  University of East Anglia (UEA); 
•  University of East Anglia Medical Centre (UEAMC); 
•  Legal Representatives for 
•  Legal Representatives for 
•  North Norfolk Clinical Commissioning Group (NNCCG); 
•  Cambridge University Hospitals NHS Foundation Trust; 
•  Legal Representatives for 

; 

; 

; 

I have also sent it to the following who may find it useful or of interest: 

•  The family of 

; the family of 

; the family of 

; the family of 

; 
, Chair of the Royal College of Psychiatrists; 

• 
• 
•  The PHSO Lead with continuing responsibility for the ‘PHSO Raising the Alarms Report’; 
•  The Chair of the Public Administration and Constitutional Affairs Committee now responsible for the 

, Deputy Leader of the Liberal Democrats, House of Lords; 

‘Follow up Report to the PHSO Raising the Alarms Report’; 

, Chair of the Adult Eating Disorder Expert Reference Group; 

, Chief executive of Cambridgeshire  LMC; 
, Chief Executive of Beat (beating eating disorders); 

, Kings College London; 

, Lead Medical Examiner for England wales 

• 
• 
• 
• 
• 

I am also under a duty to send a copy of your response to the Chief Coroner and all interested 
persons who in my opinion should receive it. 

I may also send a copy of your response to any other person who I believe may find it                     useful or of 
interest. 

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may 
send a copy of this report to any person who he believes may find it useful or of interest. 

You may make representations to me, the coroner, at the time of your response, about the release or 
the publication of your response. 

9 

 3rd March 2021 

 Sean Horstead 

 HM Assistant Coroner, Cambridgeshire & Peterborough 

6

Responses

4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Department of Health Social Care (PDF)

From Nadine Dorries MP
Minister of State for Patient Safety,
Suicide Prevention and Mental Health

39 Victoria Street
London
SW1H 0EU

28 April 2021

Mr Sean Horstead
HM Assistant Coroner,

Cambridgeshire and Peterborough

HM Coroner's Office
Lawrence Court
Princes Street
Huntingdon PE29 3PA

Dear Mr Horstead,

Thank you for your letter of 3 March 2021 to Matt Hancock about the death of Averil Hart.
I am replying as Minister with responsibility for Mental Health.

I would like to begin by expressing my most heartfelt condolences to Averil’s family, friends
and loved ones. I am deeply saddened by the failings in care highlighted in your report.
That Averil’s death was avoidable and contributed to by neglect is extremely distressing.

I also wish to express my deepest sympathies to the families and loved ones of

who you include in your

report. It is clear that we must do all we can to implement the learnings from these tragic
deaths to ensure the safety and quality of eating disorder services.

Eating disorders are serious, life-threatening conditions and improving services in England
is a priority for this Government. We want to ensure that everyone affected has access to
the right support, in the right place, at the right time.

Your report raises important concerns regarding adult eating disorder treatment. Following
the Parliamentary and Health Service Ombudsman (PHSO) report ‘Ignoring the alarms:
how NHS eating disorder services are failing patients’1, regarding the death of Averil Hart,
the Department remains committed to working to address the recommendations through a
delivery group that includes representation from NHS England and NHS Improvement
(NHSEI); Health Education England (HEE); the General Medical Council (GMC); the
National Institute for Health and Care Excellence (NICE); and, the Royal College of
Psychiatrists (RCPsych). We accept the recommendations from this report and will take
them into account when planning improvements to adult eating disorder services.

1 Ignoring the alarms: How NHS eating disorder services are failing patients | Parliamentary and Health
Service Ombudsman (PHSO)

In relation to the training of medical professionals in eating disorders, we agree that
doctors should have the necessary knowledge and experience to assess patients
holistically, considering the individuals’ physical, social and psychological needs. Through
the PHSO delivery group, NHSEI is working with HEE and other partners to procure
training courses that will increase the capacity of the existing workforce to allow them to
provide evidence-based treatment to more people, as they have set out in detail in their
responses. I share your concerns on the shortage of eating disorder specialists across the
country. I understand that colleagues in the GMC; HEE and the Academy of Medical
Royal Colleges will also address this in their responses.

We recognise that eating disorders have some of the highest mortality rates of any mental
health disorder. We agree that appropriate monitoring of patients with anorexia nervosa
by primary and secondary care providers is vital to ensure everyone with an eating
disorder gets the right support.

Under the NHS Long Term Plan, we are committed to ensuring a more integrated service
across primary and secondary care for people with severe mental illnesses, including
eating disorders, and to giving 370,000 adults with severe mental illness greater choice
and control over their care and support them to live well in their communities by 2023/24.
To support improvements in mental health care more generally, including eating disorder
care, we remain committed to expanding and transforming mental health services in
England and to investing an additional £2.3 billion a year in mental health services by
2023/24.

In addition, in August 2019, the Adult Eating Disorders: Community, Inpatient and
Intensive Day Patient Care Guidance2 was published to support the delivery of effective
models of Adult Eating Disorders care. This guidance emphasises that “the ability to
comprehensively monitor and manage the physical health of all people with an eating
disorder […] is an essential function of a community eating disorder service”. We expect
commissioners and providers to adhere to this guidance.

Transformation of community-based mental health care for adults with severe mental
illness is underway in 12 national sites that have been in receipt of ongoing transformation
funding since 2019/20. Eight of these sites have received additional funding to transform
the eating disorders pathway, including early intervention for young adults with eating
disorders. Local areas will be supported to redesign and reorganise community mental
health teams to move towards a new place-based, multidisciplinary service across health
and social care aligned with primary care networks. Local areas will need to demonstrate
that they are equipped to perform medical monitoring as per the 2019 Adult Eating
Disorders guidance.

A four-week waiting time standard for adult community mental health services, including
eating disorder services, is being piloted and considered as part of the clinically led review
of NHS access standards. Further information on the definition of a potential standard will
be shared in 2021/22.

2 NHS England » Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance
for commissioners and providers

In addition, NHSEI has announced additional early intervention services for young
people aged 16-25 with eating disorders in 18 areas across the country, so young adults
seeking support could be contacted within 48 hours and begin treatment within two
weeks.

We fully agree that there needs to be improved information about the prevalence of eating
disorders. NHS Digital’s 2007 Adult Psychiatric Morbidity Survey3 (APMS) showed that up
to 6.4 per cent of adults displayed signs of an eating disorder. The latest survey,
published in 2016, did not collect information on eating disorders. However, the SCOFF
eating disorder questionnaire was included in the 2019 Health Survey England (HSE) and
showed that 16 per cent of adults aged 16 and over, screened positive for a possible
eating disorder; women were more likely to screen positive than men; and, the proportion
screening positive increased as household income decreased. While the two surveys
cannot be directly compared, the data from both provide an indication of eating disorder
prevalence in 2007 and 2019.

The consultation for the next APMS (2022) is expected to begin shortly. NHS Digital has
appointed NatCen Social Research to conduct the survey. The steering group for the
APMS includes the Department of Health and Social Care, NHS Digital, NHSEI and
NatCen. The steering group will lead the consultation and make decisions on the
questionnaires and topic areas to be included in the APMS 2022 based on the responses
received. The Department of Health and Social Care is working closely with stakeholders
and interest groups to ensure they can feed into the consultation.

In relation to your concern on the potential under-reporting of the extent to which eating
disorders have caused or contributed to deaths, I welcome your plan to explore this issue
further with the National Medical Examiner for England and Wales, the Office for National
Statistics and the Coroners’ Society of England and Wales.

Finally, we recognise that NHS eating disorder services are facing increased demand
during the COVID-19 pandemic. During the first 9 months of 2020/21, a total
of 7,555 children and young people started treatment and 84.7 per cent started treatment
within the standard timeframe. This compares with 5,831 children and young people that
started treatment in the first 9 months of 2019/20. Given the high risk presented by
COVID-19 in this group, all areas have been advised to continue prioritisation of service
delivery, and to take steps to mitigate the potential impact of COVID-19 on this vulnerable
group.

As part of the Government’s commitment to build back better post-COVID, on 27 March
we published our Mental Health Recovery Action Plan4, backed by an additional
£500million of targeted investment, to ensure that we have the right support in place over
the coming year.

As part of this funding, £79million will be used to significantly expand children’s mental
health services, enabling 2,000 more children and young people to access eating disorder

3 Adult Psychiatric Morbidity Surveys - NHS Digital

4 COVID-19 mental health and wellbeing recovery action plan - GOV.UK (www.gov.uk)

services. £58million will be allocated to accelerate the adult community support to bring
forward the expansion of integrated primary and secondary care for adults with severe
mental illness, including eating disorders.

I hope this reply helps to reassure you that we continue to be committed to ensuring that
everyone with an eating disorder has access to timely and integrated care and we are
actively working with our arm’s length bodies to improve services and data.

NADINE DORRIES

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL
HEALTH

Response from General Medical Council (PDF)

21 April 2021

Mr Sean Horstead
Cambridgeshire & Peterborough Coroner Service
Lawrence Court, Princes Street, Huntingdon
PE29 3PA

Dear Mr Horstead

Regulation 28: Report to Prevent Future Deaths

The details of the tragic circumstances of Averil Hart’s death are upsetting to read. I extend my
sincere condolences to Averil’s family and to other families affected.

You list four key concerns in your report. As the Medical Director and Director of Education and
Standards at the General Medical Council, I can respond to the first (Inadequate training of
doctors and other medical professionals re eating disorders) and also your fourth key concern
about the impact of the COVID-19 pandemic.

The provision of consistent, comprehensive medical education and training on eating disorders
(ED) remains an important issue for us since the Parliamentary and Health Service Ombudsman
(PHSO) identified concerning themes in their 2017 ‘Ignoring the Alarms’ report. I appeared before
the Public Administration and Constitutional Affairs [Select] Committee in 2019 to give evidence
about our progress towards the PHSO’s recommendation that we review training for all doctors.
The written evidence I submitted may be helpful as it details our regulatory role, our requirements
for doctors, and our early actions in response to the PHSO report. Since then, we’ve used our
regulatory powers and influence to find solutions to inconsistency in training to address patient
safety concerns.

I will summarise our role as a regulator and how it relates to the education and training of doctors
around ED, and then describe the actions we’ve taken since the PHSO report.

Our role as a medical regulator

Our powers in medical education, as set out in the Medical Act 1983, are two-fold: to set the
outcomes for graduates of UK medical schools leading to entry on to the medical register, and to
approve the curricula for postgraduate training of doctors. We quality assure both aspects of
medical training against our standards for the management and delivery of medical education and
training. The principle of patient safety drives our work.

Medical education must adapt to the needs of society and be appropriately responsive to patients
and the public. We keep our standards and requirements for medical education up to date with
timely revisions to make sure they reflect changing patient needs as well as contemporary medical
practice, scientific basis, and professional behaviours. We review our guidance to make sure it
keeps up to date with new information and developments in healthcare.

Undergraduate education

We determine and publish the high-level outcomes all medical students are required to
demonstrate in order to graduate. We updated our ‘Outcomes for graduates’ in 2018 after
extensive consultation. Our powers don’t extend to mandating specific content in undergraduate
curricula, but the outcomes do describe relevant key themes around mental health, nutrition, and
vulnerable groups. We required schools to embed the new outcomes in undergraduate curricula
for all students commencing academic year 2020/21. However, many schools had already
introduced changes to their curricula for current student cohorts.

To keep driving improvement, we’re introducing a new way of assessing medical students, as well
as international medical graduates, that will ensure they meet a common and consistent threshold
for safe practice before they’re licensed to work in the UK. The Medical Licensing Assessment will
be based on a comprehensive content map which sets out the range of skills and knowledge that
students will be required to have and could be tested on. The content map is available on our
website. It includes eating disorders. All students graduating from UK medical schools from the
academic year 2024/25 will need to pass the new assessment, which will also replace our current
test for international medical graduates in early 2024.

Foundation Programme

All doctors enter the two-year Foundation Programme after graduating from medical school. It
trains graduates to develop a range of essential interpersonal and clinical skills for managing acute
and long-term conditions. The Academy of Medical Royal Colleges (AoMRC) develops the
Foundation Programme curriculum, which describes specific outcomes all Foundation doctors
should demonstrate on completion of the programme. Our regulatory role is to approve the
curriculum. It requires doctors to show skills including: recognising eating disorders, referring to
specialist services, addressing nutritional needs, and communicating these during care planning,
formulating recovery plans, and investigating and managing weight gain.

Specialty training

The curricula for postgraduate specialty training are set by individual medical royal colleges and
faculties. We approve them against our standards for postgraduate curricula. In 2017 we
published new standards requiring curricula to be mapped against our framework of shared
generic and specialty-specific outcomes. Our ‘Generic professional capabilities framework’ sets the
essential capabilities which underpin professional medical practice and are a fundamental part of
all postgraduate training programmes. The capabilities include mental health, nutrition,
safeguarding vulnerable groups, communication, leadership, and multidisciplinary team (MDT)
working. Most specialty curricula have now been mapped to the new outcomes. Specific

requirements for identifying, assessing, and safely managing patients with ED are specified in a
number of relevant specialty and GP curricula.

Changes we’ve made to the training of doctors re eating disorders

You highlight that there is a widespread and continuing lack of training, knowledge, or experience
on the part of doctors and other healthcare staff. The provision of education and training on ED is
evidentially inconsistent and sometimes insufficient to prepare all doctors to recognise and manage
or refer patients with ED. Since the PHSO report, we’ve taken actions in collaboration with others
to strengthen education and training around ED.

Crucial to preventing future deaths is for all doctors to have skills to recognise ED and support
care, including the recognition and management of emergencies such as life-threatening nutrition.
Patients may present to doctors in various contexts with other symptoms and complications, which
could include: diabetes, abdominal issues, fertility problems, suicide attempts, and multiple others.
Every interaction with patients is an opportunity to identify and act on these signs. The earlier they
are picked up, the more treatable the underlying ED. Doctors’ capabilities in ED should become
progressively more complex as their responsibility for, or level of exposure to patients who have
eating disorders, increases.

It is acknowledged that early intervention for ED is crucial to successful treatment. This means
doctors have a pivotal role to play in identifying the potential that a patient presenting to them
with varying symptoms may have an eating disorder. We are asking education providers to reach
an agreed core set of knowledge and skills for all doctors to be able to draw on in critical meetings
with patients, although enforcing exactly what education providers teach is not within our remit.

Survey of medical schools

To build a better picture of coverage in undergraduate curricula, I sent a letter to all medical
schools in 2019 raising the issue and requesting details of teaching in ED. All 35 medical schools
responded with helpful detail on how students are taught about ED. The survey identified some
good practice but also areas where education and training could be improved. There was
variability across schools in coverage, in links between teaching on mental and physical health,
and in exposure to patients with ED. We are working with schools to ensure coverage is improved
and especially the link between physical and mental health. We reported our findings to schools,
highlighting both good practice and gaps, and suggesting schools work together to develop a
shared approach. We’re currently working with schools, in collaboration with Beat, the eating
disorders charity, to address these gaps and bring consistency to undergraduate education on ED.

Training resources

We supported Beat, the eating disorders charity, in their development of new all-encompassing
training resources, with expertise from the Royal College of Psychiatrists’ Faculty of Eating
Disorders, which are available to use as of March 2021. They introduce students and Foundation
doctors to the knowledge, skills, and tools they need to identify, diagnose and treat or refer
patients. We’re working with representatives from the UK Foundation Programme as well as the

Medical Schools Council and education and curriculum leads from individual medical schools to
develop implementation plans for the new resources. Although there are pressures on space in the
curriculum, encouragingly, education providers have expressed enthusiasm to make use of this
helpful resource. We hope that teaching on ED will be embedded in their teaching programmes.
We’ll include this in our quality assurance of medical schools in 2022 to ask about changes they
implemented, or if they need further support. We hope that this will give schools time to embed
the new training resource. Data from the e-Learning platform will help us to monitor uptake of the
training and consider what further work is required.

Shared learning across postgraduate specialities

We are working with the AoMRC on the details for a process to identify and develop areas where
key learning can be shared in postgraduate training across the various specialties and
subspecialties. The aim of this will be to ensure high standards in core clinical areas. We have
asked that one of the case studies to test the shared learning process must be ED. As the shared
learning work develops, we will feed into the AoMRC’s work that these skills are needed. The
process to identify and develop shared learning across specialties will consider post-qualification
development as part of a programme of lifelong learning across a doctor’s career. We expect this
work will begin later in 2021.

Health Education England (HEE) and NHS England/Improvement (NHS E/I) have developed
intensive ‘whole team’ adult eating disorder training with expertise from the Royal College of
Psychiatrists’ Faculty of Eating Disorders, where specialist ED or non-specialist e.g. GP practice
team members jointly acquire the knowledge and skills to enable the safe and effective
management of patients with ED. We welcome the initiative by HEE and NHSE/I, and we’re
actively following HEE and NHSE/I’s work. As it matures, we will consider ways to showcase this
whole team ED training as good practice, and as part of our lifelong learning strategy to enable
doctors to develop throughout their career.

Progress towards the PHSO recommendation

I hope this assures you that we have already taken significant actions within our powers to
address the concerns you raise. I have also identified areas where we can take further actions
and have indicated timelines for these.

Shortage of ED specialists

The final point you raise as part of the first concern is that there is a serious shortage of ED
specialists. We’ve heard evidence of a continuing shortage of ED specialists across the country,
with many trusts finding it difficult to fill vacancies. These shortages inevitably impact on the level
and quality of support available to primary care providers and other specialists. Your report
evidences this staffing crisis, whereby heavy workloads with insufficient staffing compounded
failings in Averil’s care. Although workforce issues are not specifically within our powers, we are
working with the workforce bodies and health care providers across the UK to identify and
implement solutions.

The impact of the COVID 19 pandemic

You identify a concern that the pandemic increases the risk of further deaths because it has
impacted all aspects of care, including training. The pandemic has impacted on training across all
countries of the UK and in different ways for the differing specialties. A lot of teaching was moved
online, but the clinical experience was inevitably affected. We are working with medical schools,
the MSC, the national education bodies and service providers to re-establish all training
opportunities as quickly as possible. We continue to work with education providers to ensure
students and doctors in training can meet their outcomes and progress safely, and we’re reviewing
the impact of the pandemic on training.

The pandemic also impeded our plans for this work in 2020. We had planned to follow up with
medical school Deans one year after our 2019 survey, but we decided to postpone this measure
since schools faced significant disruption. Instead, we communicated with schools in other ways,
by contributing to a letter HEE sent to schools encouraging uptake of the new training resources,
as well as communicating directly with medical school education leads and the Medical Schools
Council.

Final reflections

Thank you for highlighting these important issues in your report. Better care for ED is so
important, especially considering its growing prevalence. We’re committed to providing workable
solutions to address the risk of insufficient training, knowledge, and experience of doctors. We
believe the changes we’re making to enhance medical education and training will contribute to
improved patient outcomes, and we will monitor progress to ensure they are effective. I’m
extremely grateful for the efforts of our partners in this work who’ve collaborated to achieve
significant goals in better care for people with eating disorders.

Yours sincerely

Medical Director and Director of Education and Standards

Response from Health Education England (PDF)

By Email:  

Sean Horstead,  
HM Assistant Coroner,  
Cambridgeshire & Peterborough  

Department of Education and Quality 
2nd Floor Stewart House  
Russell Square  
London 
WC1B 5DN  

30th April 2021  

I write in response to your report of 3rd March 2021, made under the Coroners (Investigations) 
Regulations 2013 (“the Regulations”). May I begin by extending my sincere condolences to Miss 
Hart’s family following her tragic death from Anorexia Nervosa (AN). Every death is a tragedy 
and whilst your report is difficult reading, we have shared it widely in our organisation so that our 
staff can see the impact on families and ensure our focus remains on working with partners and 
families to improve Eating Disorder services.      

Your report raises concerns regarding the training of doctors and other medical professional 
regarding eating disorders (ED). As you note, the 2017 Parliamentary Health Service 
Ombudsman (PHSO) Report, Ignoring the alarms, made recommendations regarding training for 
doctors about eating disorders. This recommendation was more recently reiterated in the Public 
Administration and Constitutional Affairs Committee (PACAC) Follow-up Report, published in 
2019. Whilst there are many reports detailing widespread issues for patients and families, many in 
HEE have experience of services as clinicians who are working on solutions and have contributed 
to this response. 

To respond to your concerns, I will first clarify Health Education England (HEE)’s role, and how we 
work with partners to plan, recruit, educate and train the health workforce. I will also provide an 
update on the measures that HEE has taken in response to the PHSO and PACAC 
recommendations regarding education in eating disorders. 

Health Education England (HEE) is the executive non-departmental public body responsible for 
promoting high quality education and training for the healthcare workforce in England. We fund 
and manage the highest quality education and training to deliver high quality health professionals 
who work effectively in multi-disciplinary teams for the benefit of patients. As well as planning for 
and training our future workforce, we are committed alongside employers and other stakeholders 
to the development of the current NHS workforce. 

The standards for medical education in the UK are set by the independent professional regulator, 
the General Medical Council (GMC). Each individual medical school sets its own undergraduate 
medical curriculum, which must meet the standards set by the GMC, who then monitor and check 
to make sure that these standards are maintained. The curricula for postgraduate specialty training 
are set by individual royal colleges and faculties, and the GMC approves curricula and assessment 
systems for each training programme. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 HEE funds clinical placements for undergraduate doctors and pre-registration healthcare students, 
and commissions postgraduate medical training in England. We set our expectations for the quality 
of the educational environment in our multi-professional Quality Framework. The overarching 
objective of Framework is to promote inter-professional learning and to support and facilitate 
service transformation that meets current and future patient needs. 

We also have a key role in supporting service development and delivery of the NHS where key 
priorities, including ED, require additional post qualification training and education support to the 
system.  We have several mechanisms to do this, including system transformation, workforce 
development funding and continual professional development (CPD) programs.  

Doctors in training 

Our Postgraduate Deans and Foundation School Directors manage the quality of postgraduate 
medical education and work with employers to design training programmes that equip doctors 
with the skills they need to provide high-quality patient care. Since the publication of the PHSO 
and PACAC reports, HEE has introduced changes to medical education to improve mental 
health awareness across the medical profession. This includes HEE commissioned learning 
resources for medical students and Foundation 1 and 2 doctors provided in partnership with BEAT 
and the Royal College of Psychiatrists.   

As set out in Stepping forward to 2020/21: The Mental Health Workforce Plan for England, 
published in July 2017, HEE is working with the Royal College of Psychiatrists (RCPysch) to 
address the fill rates in psychiatry specialty training. Part of this work has resulted in an increase 
in the number of doctors in the Foundation Programme working in a four-month psychiatry post 
to 47% nationally in 2018, and HEE continues to work with the RCPysch to improve on this. 

HEE is also working to develop and pilot enhancements to GP training. One of the priorities for 
this reform is to enhance the delivery of the mental health elements of the GP Specialty 
Curriculum. This includes increasing GP trainee time in General Practice to 24 months from 
18months and ensuring that all GP trainees are able to gain enhanced experience in the 
treatment of mental health in primary care settings.   

Wider clinical workforce 

For the wider healthcare workforce, HEE’s National Mental Health Programme has undertaken a 
project to scope eating disorder training nationally, mapping what currently exists in order to 
understand existing training and professional presence/skills across the Eating Disorders 
pathway.  We know that all of us in the NHS  need to do more to facilitate patient access to high 
quality safe interventions, particularly between physical and mental healthcare, and between 
general and specialist services. 

Stepping Forward to 2020/21: The Mental Workforce Plan for England (HEE 2017) set out a high 
level roadmap and reflected the additional staff required to deliver mental health service 
transformation based on best evidence. The December 2020 data, which is the latest available, 
demonstrates that the mental health workforce has increased by 14,480 WTEs since March 2016, 
many of whom will be delivering care for eating disorder services across the different pathways. 

The 2020 Mental Health Implementation Plan (MHIP) builds on the ambition to grow the 
workforce by a further 27,460 by 2024. In addition to the Stepping Forward and MHIP workforce 

 
 
 
 growth targets, education programmes are being commissioned to upskill the existing workforce 
working with children and adults in psychological therapies and eating disorder treatments. This 
training is provided across the whole of the mental health workforce ranging from specialist 
practitioners such as in CBT in eating disorders, teams via Whole Team Training and general 
awareness such as upskilling junior doctors and nurses.  

Many of the expanded workforce will be delivering psychological interventions for people with an 
eating disorder, the growth of which has been complimented by the HEE provision of 4,500 adult 
Improving Access to Psychological Therapies practitioners. For children and young people we 
have recruited 700 new practitioners and trained 3,400 existing NHS staff between 2016 and 2021. 
HEE has also increased the number of clinical psychologists in training by 25% in 20/21 and 21/22.  
A psychological professions workforce plan is in train which will map the further expansion of, 
psychological therapies and related roles to guide local workforce planning and education 
provision. 

In order to gain a comprehensive understanding of eating disorder education and training needs, in 
2019 HEE commissioned an England wide benchmarking report, to inform the planning and 
discharge of future training commissions and to develop a comprehensive compendium of 
training., This is now being used to support regional system leaders and local services to manage 
training in response to local need, drawing on learning resources already available and further 
training opportunities via HEE commissions. 

The additional commissions we subsequently made included Cognitive Behaviour Therapy 
specifically for eating disorders, delivered via whole team training from late 2020. This training 
covers the whole range of expertise, including ED specialists (70 trained) as well as well as other 
staff delivering care in eating disorders services (270 trained to date). 

To further support the expansion of psychological therapies provision, in March 2021 HEE 
commissioned the development of a national curriculum and commissioning specification for the 
Maudsley Model of Anorexia Nervosa Treatment for Adults to enable a nationally consistent 
approach. 

HEE has also commissioned BEAT to develop a programme for all nursing staff to gain confidence 
to understand, respond compassionately, and appropriately signpost clients with eating disorders. 

Further to this, in support of the whole workforce, HEE has developed the ‘Psychological 
Interventions for People with Eating Disorders: A competence framework in partnership with 
University College London, which is aimed at all health workers, trainers and supervisors, clinical 
managers and service commissioners to guide workforce capability development and enhance 
patient safety. In 2021/22, HEE will be working with NHSE/I to develop physical health check 
training relating to eating disorder, that is supported by the Physical Health Competency 
Framework for Mental Health and Learning Disability Settings (HEE December 2020) 

HEE is currently working with NHSE/I within a joint eating disorder expert advisory group to ensure 
effective planning for future commissioning activities and determine the workforce requirements of 
eating disorder services across the demographic. This work will include the urgent development of 
an education and training commissioning framework agreement. 

 
 
 
 
 
 
 
 
 E-Learning for Health 

In addition to the above, HEE runs an e-learning platform called e-Learning for Health (e-LfH), 
working in partnership with the NHS and professional bodies to support patient care by providing 
e-learning to educate and train the health and social care workforce. 

HEE has a range of high quality training available via its e-Learning arm, e-Learning for 
Healthcare, around eating disorders, particularly on its MindEd programme, which is targeted at 
professionals and their families. This training, which is available nationally and accessible  24/7, 
includes, but is not limited to: 

•  Anorexia and Bulimia 
•  Eating Disorders in Young People 
•  Combining therapies to support young people with an eating disorder. 

These titles include a new programme for medical students and foundation doctors, developed in 
response to the PHSO investigation into avoidable deaths from eating disorders in partnership 
with RCPsych and the eating disorder charity, Beat. The programme, launched in March this 
year, is designed to ensure that all medical students and foundation doctors are trained to 
understand, identify and respond appropriately when faced with a patient with a possible eating 
disorder. A full list of eating disorders materials hosted by HEE e-LfH is appended to this 
response.  

******************* 

I hope this response provides you with the assurance that HEE is committed to taking the 
learning from the tragic death of Avril Hart and is working proactively with partners to better 
equip the healthcare workforce to recognise, diagnose and treat patients with eating disorders, to 
improve experiences and outcomes and ultimately save lives. This includes work to expand the 
mental health workforce, to enhance medical education pathways and produce doctors with a 
greater understanding of mental health and wellbeing, and to develop world-class eating 
disorders education resources.  

Yours Sincerely, 

National Director of Education & Quality and Medical Director

Response from NHS England and NHS Improvement (PDF)

Sean Horstead, Assistant Coroner,  
Coroner area of Cambridgeshire & 
Peterborough 
Coroner’s Service,  
Lawrence Court,  
Princes Street,  
Huntingdon  
PE29 3P 

                          National Medical Director 
                                          Skipton House 
                                         80 London Road 
                                                     SE1 6LH 

4th May 2021 

Dear Mr Sean Horstead,   

Re: Regulation 28 Report to Prevent Future Deaths – Averil Miranda Hart 
(15.12.2012)  

Thank you for your Regulation 28 Report dated 3rd March 2021 concerning the 
death of Averil Hart on 15.12.2012. Firstly, I would like to express my deep 
condolences to Averil Hart’s family.  

The inquest concluded that Averil Hart’s death was a result of 1a Anorexia Nervosa 
but death was avoidable and that it was contributed to by neglect.  

Following the inquest, you raised concerns in your Regulation 28 Report to NHS 
England and NHS Improvement (amongst other organisations) regarding: 

Inadequate training on eating disorders for doctors and other medical 

• 
professionals  
Lack of formally commissioned service level agreement for the provision of 
• 
robust and effective monitoring of moderate to high risk Anorexia Nervosa patients 
by primary or secondary care providers 
• 
• 
I understand that colleagues in other organisations will also be responding to this. 
My response will therefore focus on what we are doing to improve adult eating 
disorder services in the NHS, both nationally and within the East of England region.  

Lack of robust and reliable data regarding the prevalence of eating disorders 
The impact of the COVID-19 pandemic 

Eating disorders (ED) are serious, life-threatening conditions with some of the 
highest mortality rates of any mental health disorder. Improving eating disorder 
services is a key priority for NHS England and Improvement (NHSEI) and a 
fundamental part of our commitment to expand and improve mental health services. 
We have developed a national programme of work, backed by significant 
investment committed as part of the NHS Long Term Plan, to ensure that 
systemwide changes to improve adult eating disorder services are delivered at 
pace.   

Adult Eating Disorder Service Transformation and Funding    

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
                          
 
                                                        
                
 The NHS Long Term Plan commits to the implementation of new integrated models 
of primary and community mental health care that improve care for adults and older 
adults with a range of severe mental health problems, including eating disorders, in 
all Sustainability and Transformation Partnerships (STPs) in England by 2023/24.  

All STPs/Integrated Care Systems (ICSs) are required to start work to transform 
their community eating disorder (CED) pathways in line with published guidance by 
2023/24. Local plans submitted to NHSEI indicate that at least 22 ICSs are starting 
this transformation in 2021/22, and have dedicated over £6m. All other areas due to 
commence in 2022/23.  

To support local strategic planning and development of transformed ED pathways 
in line with published guidance, regional adult eating disorder clinical leads have 
now been appointed across England.    

Additionally, NHSEI has additional implementation support available in 18 sites 
across the country to embed First Episode Rapid Early intervention for Eating 
Disorders (FREED) to support early intervention services for young people, aged 
16-25, with an eating disorder.   Use of the FREED model means people coming 
forward could be contacted within 48 hours and could begin treatment within two 
weeks. Evidence shows that this model reduces the waiting times for assessment 
and treatment and that patients experience better outcomes.   

Medical monitoring and the role of Primary Care  

National action 

NHSEI issued national guidance in August 2019 which sets out a clear expectation 
that CED services develop integrated pathways with primary care and where 
responsibility for medical monitoring sits. The guidance outlines that “Medical 
monitoring needs to be based on local medical monitoring agreements clearly 
established across the CED service and primary care network, with one consistent 
protocol agreed on by local commissioners.” and includes the following table setting 
out responsibilities: 

We are committed to ensuring a more integrated service across primary and 
secondary care for people with severe mental illnesses, including EDs, and NHSEI 
have a Long Term Plan ambition to give 370,000 adults and older adults with 
severe mental illness greater choice and control over their care and support them to  

live well in their communities by 2023/24.  

NHS England and NHS Improvement 

 
  
 
 
 
 
 
 
 
 
  
  
 
 In order to receive system development funds for the expansion of adult community 
eating disorder services, when developing funding bids STPs were required to 
“be clear on the arrangements for medical monitoring in partnership with primary 
care to manage the physical health needs of people with eating disorders”.   

In 2019/20 and 2020/21, 12 STPs/ICSs were funded to test new models of 
integrated care, which will include CED. Eight of these sites chose to focus on 
improvements to CED services as a specialty area.  We will ensure that the learning 
from the community early implementers sites will be shared via the Adult ED 
Clinical Leads forum to support services as they embed robust medical monitoring 
pathways.  

In addition, the 2021/22 GP contract and Standard Contract are embedding mental 
health practitioners in Primary Care Networks (PCNs). Although these practitioners 
will not directly undertake the medical monitoring themselves, they will be able to 
liaise with the staff who will undertake it and help to ensure adequate oversight of 
the care of patients with severe mental illnesses, including eating disorders,  across 
primary and secondary care.   

Additional East of England actions underway 

Further work to support formal commissioning arrangements for medical monitoring 
will be led by the Eating Disorders Strategic Oversight Board which reports to the 
East of England Regional Mental Health Strategy and Transformation Board. 
Since the death of Ms Hart, both Cambridgeshire & Peterborough (C&P) and 
Norfolk & Waveney (N&W) Clinical Commissioning Groups (CCGs) have taken 
steps to improve commissioning arrangements for medical monitoring.  C&P CCG 
are piloting a commissioned medical monitoring pathway (initially within 
Peterborough with a view to rollout across the CCG) as part of the Adult Community 
Mental Health Transformation Programme and N&W CCG has an established route 
for people living with EDs to receive medical monitoring in primary care through a 
Locally Commissioned Service (previously termed Local Enhanced Service or 
LES).  Both CCGs continue to work in establishing improved and more equitable 
access to ED pathways of care. 

Training   

National action  

NHSEI are working with Health Education England (HEE) to improve workforce 
training for the adult eating disorder workforce. This is in line with NHS Long Term 
Plan commitments and backed by significant investment (funding in place up to 
2023/24).   

The training courses that are being offered / developed include:  

Adult Eating Disorder Whole Team Training (WTT): to ensure that the 

• 
entire team has the skills necessary to function effectively and safely within an 
eating disorder service. WTT is open to primary care staff.  In 
2020/21 approximately 240 staff (from around 90 teams) were enrolled in the WTT 

NHS England and NHS Improvement 

 
  
  
 
 
 
 
 
  
 
 Maudsley Model of Anorexia Nervosa Therapy for Adults 

Cognitive Behavioural Therapy for Eating Disorders (CBT-ED): This a 

training course nationally. The length of this course will vary per service and will be 
organised to ensure continuation of service, so it is expected that some of 
this cohort will have completed this training in 2021/22.   
• 
post-graduate course for mental health professionals and once completed will give 
individuals the skills to provide this NICE recommended (NG69), evidenced-based 
therapy.  In 2020/21, 47 staff were enrolled in the CBT-ED training course, 
nationally. This is a 1-2 year course (depending on prior qualifications).  
• 
(MANTRA): MANTRA is a cognitive-interpersonal treatment. This course is aimed 
at experienced mental health professionals, to provide them will the skills necessary 
to deliver this evidence based and NICE recommended treatment.   A training 
provider will be commissioned to deliver this course in 2021/22.   
• 
people with lived experience to develop a training offer that will support services to 
provide guided self-help (NICE recommended for binge eating disorder and bulimia-
nervosa).  Curriculum development for GSH is currently planned to take place in 
2021/22.   

Guided Self-Help (GSH): We plan to work with HEE, ED clinical experts and 

MARSIPAN  
The published guidance links to the MARSIPAN (Management of Really Sick 
Patient with Anorexia Nervosa) guidance. Providers and commissioners are 
encouraged to develop pathways and protocols in line with this advice. The use of 
MARISPAN in inpatient settings is being promoted through the development of 
quality frameworks in the adult eating disorder Provider Collaboratives.   

Wider training  

NHSEI agree that it is imperative that doctors and other medical professionals 
receive sufficient training on mental health and in particular eating disorders to 
support parity of esteem and improve patient care. 

This is not within our gift to deliver but we stand ready to support HEE, the General 
Medical Council and partners in their efforts to achieve this objective.  

I would recommend that this report is extended to the Medical Schools Council; 
who are able to influence the curriculums and training standards for doctors and 
medical professionals, in order to support this work.  

Additional East of England actions underway 

The regional East of England mental health team have worked jointly with HEE to 
support education and guidance to systems in managing eating disorders, with 
learning to be shared.  This has included: 
• 
Several webinars, learning events and annual conferences to target all 
professionals who support people with eating disorders and parents/carers.   
• 
access training for medical staff in managing patients who present at A&E or 
require admission to a medical ward for self-harm or an eating disorder that 
requires medical stabilisation.  Cambridgeshire & Peterborough (C&P) and Norfolk 

Funding has also been made available for all acute trusts in the region to 

NHS England and NHS Improvement 

  
 
 
 
 
 
 
 & Waveney (N&W) both now offer specialist ED training to all primary care 
clinicians in GP practices and outside of primary care. 
• 
The East of England Regional Mental Health Strategy and Transformation 
Board is supporting Trusts to develop comprehensive policies and procedures to 
manage patients with Anorexia Nervosa, in line with the MARSIPAN guidelines  

Prevalence data  
NHSEI recognise and agree that there is a need to improve the data on the 
prevalence of eating disorders in adults. We have joined the APMS steering group 
(alongside DHSC and other ALBs) to influence the questionnaires that are included 
in the next survey to ensure representation of eating disorders.  

Impact of the COVID-19 Pandemic    

Despite the challenges of the pandemic, mental health services have remained 
open and CED service have been working hard to minimise disruptions in care by 
using virtual platforms for appointments and social media to continue support. 
Where face to face appointments were needed, services acted in line with safety 
protocols to protect themselves and their patients.   

In the April 2020 we held a national webinar to share key messages with service 
providers and commissioners, to support service continuation throughout the 
pandemic and beyond this we will continue to support services via the regional 
clinical leads.   

During the initial phase of the COVID-19 pandemic some aspects of transformation 
work within our 8 Adult ED early implementer sites were slowed or paused due to 
the need to prioritise the immediate COVID-19 response. However, despite the 
pandemic, progress continues with new, expanded or transformed services going 
live over recent and coming months.  

Finally, an extra £500m has been announced for Mental Health services to respond 
to the rising level of need from the pandemic, which includes an additional £58m to 
support the additional expansion of community services for people with severe 
mental illness, including people with an eating disorder.   

Thank you for bringing these important patient safety issues to my attention and 
please do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director   
NHS England and NHS Improvement  

NHS England and NHS Improvement

The report

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