Charlotte Swift

Attention: Mrs Penelope Schofield   

Worthing Coroner's Office 
Centenary House, 
Durrington lane, 
Worthing, 
BN13 2QB 

National Medical Director  
NHS England & NHS Improvement  
Skipton House 
80 London Road 
London 
SE1 6LH 

3rd September 2021   

Dear Mrs Penelope Schofield,  

Re: Regulation 28 Report to Prevent Future Deaths – Charlotte Lucy Swift  -
09/04/2021  

Thank you for your Regulation 28 Report dated 11th May 2021 concerning the sad 
death of Charlotte Lucy Swift on 9th April 2020. Firstly, I would like to express our 
sincerest condolences to Charlotte’s family.  

The regulation 28 report concludes Charlotte’s death was a result of natural causes 
associated with anorexia nervosa and following the inquest, you raised concerns in 
the report to NHS England regarding the wait for a specialist eating disorder inpatient 
bed. You also advised evidence given at the inquest indicated there was a national 
shortage of inpatient beds/placements and this was putting individuals at risk. 

NHS England and Improvement (NHSEI) understand that eating disorders are 
serious and life-threatening conditions and are committed to improving eating 
disorder services. We have developed a national programme of work backed by 
significant committed investment to ensure that systemwide changes to improve 
eating disorder services are delivered. NHS England (NHSE) has provided the 
response below considering the concerns you have raised, giving explanation to the 
changes that are taking place now, and in the near future. 

Optimal Service Model for Eating Disorders 
By way of an overview as to current guidance and model of service, clinical 
consensus and guidance on eating disorders from the National Institute for Health & 
Care Excellence (NICE) indicates that the optimal model of service delivery for 
people with an eating disorder is a dedicated, multidisciplinary Community Eating 
Disorder (CED) service. Care should be delivered in the community, supported by 
intensive day patient or inpatient treatment only when required for people with a high 
level of physical or psychiatric risk that cannot be managed safely in the community. 
Adult eating disorder services should provide a seamless pathway for young adults 
supporting a positive experience of transitioning from children and young people 
(CYP) CED services where needed and avoiding unhelpful ‘cliff edges in care’.  

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The focus of the eating disorder pathway is early community intervention and access 
should be based on clinical need, not Body Mass Index (BMI). The NICE guidelines 
state that ‘single measures such as BMI or duration of illness’ should not be used to 
determine whether to offer treatment for an eating disorder. This is reiterated in the 
CYP Eating Disorder guidance which also includes the role of paediatricians within 
the eating disorder community teams. This guidance was extended in 2019 to 
support implementation of NICE recommendations on improved integration with 
inpatient settings and to share helpful resources on best practice.  

National Policy – NHS Long Term Plan (LTP) 
Following significant expansion by NHS England (NHSE) of services for children and 
young people with eating disorders since 2015, there is now increasing commitment 
and a requirement under the NHS Long Term Plan (LTP) across a range of 
stakeholders to improve both timely access to, and the quality of evidence-based 
treatment in eating disorder services for adults and older adults. National policy 
establishes a clear rationale for localities to focus on improving care for individuals 
with eating disorders.  

As part of the LTP, local areas will be supported to redesign and reorganise 
community mental health services to move towards a new place-based, 
multidisciplinary service across health and social care aligned with primary care 
networks. Improving access to services for adults with eating disorders is a priority 
for the NHS as part of the LTP for mental health.  

Progress to date against LTP 
Service Expansion & Re-modelling 
New and expanding community-based mental health care will provide treatment and 
support for 370,000 adults - including those with eating disorders - closer to home, 
and the NHS committed to increasing investment in mental health services faster 
than the NHS budget creating a new ringfenced local investment fund worth at least 
£2.3 billion a year by 2023/24, which will be used to provide patients with greater 
choice and control over their care and support them to live well in their communities.  

LTP funding for 2021/22 is accompanied by a Delivery Plan for Mental Health, which 
asks all services undertaking Adult Eating Disorder (AED) transformation to: 

• 

• 

Increase clinical and non-clinical capacity in AED services to meet spend and 
access trajectories set out in community transformation plans 
Increase number of patients and reduce waiting times for support and 
intervention in AED pathways 

•  Ensure AED pathways remove any barriers to access (e.g., weight or BMI), 
can accept self-referrals and VCS referrals, and are implementing early 
intervention models e.g., FREED 

•  Ensure AED pathways have medical monitoring protocols in place with 

primary care 

Alongside this work,  NHS led Provider Collaboratives create the opportunity to 
redesign the pathway for adults and CYP with eating disorders bringing care closer 
to home by giving them the responsibility for managing the budget associated with 
the specialist care for this group. Therefore, through a rebalancing of provision, and 
moving away from a focus on inpatient services to a model of expansion of 

 
 
 
 
 
 community-based services, adults with eating disorders will be able to access 
treatment earlier, and closer to home, leading to better outcomes for them and their 
families.  

Additionally local plans submitted to NHSE indicate that at least 22 Integrated Care 
Systems (ICSs) are starting work to transform their community AED pathways in line 
with published guidance in 2021/22, with over £6m of initial dedicated investment, 
with remaining ICS localities due to commence in 2022/23 while in 2019/20 and 
2020/21, 12 STPs/ICSs “Early Implementers” were funded to test new models of 
integrated care, including improvements to Community Eating Disorder services. 
Learnings from these sites will be shared wider with systems and help inform future 
development and to further support local strategic planning and development of 
transformed AED pathways in line with published guidance, regional adult eating 
disorder clinical leads have now been appointed across England.    

Early Intervention 
Early intervention is critical for those with eating disorders. In 2019/20 NHS England 
funded 18 eating disorder services to implement the early intervention model - First 
Episode Rapid Early Intervention for Eating Disorders (FREED), to support the early 
identification of eating disorders to support young people in the early stages of eating 
disorders and ensure they can access services sooner. FREED is an evidence-
based early-intervention model, for people aged 16-25, presenting with a first 
episode of eating disorders that has lasted for less than three years.  Evidence 
shows that this model reduces the waiting times for assessment and treatment and 
that patients experience better outcomes.  

The implementation of FREED is part of a broader ambition to create a more 
comprehensive and integrated mental health offer for 0-25 year olds, which sees 
children and young people’s and adult eating disorder services working together to 
improve the pathway of care for young adults. 

Training 
NHSE are also working in partnership with Health Education England (HEE) to 
deliver a comprehensive training programme to improve the support received by 
those with eating disorder, including training in cognitive behavioural therapy for 
eating disorder, and other evidence-based interventions. Around 240 staff (from 
around 90 teams) have received training in how to better support those with an 
eating disorder diagnosis and training numbers are set to increase this year. 

Specialised Commissioning for inpatient eating disorder beds 
The high level of demand for access to Specialised Commissioning AED inpatient 
beds is being addressed through the development of the Provider Collaboratives and 
new models of care considering the whole patient pathway from Primary Care to Tier 
4 national services. The implementation of NHS-Led Provider Collaboratives began 
in October 2020, with 19 NHS-Led Provider Collaboratives now live and the 
remaining Phase One Provider Collaboratives being implemented by 1 October 
2021.  

NHS-Led Provider Collaboratives seek to transform care pathways for people who 
need specialised services, covering both the CYP and AED inpatient pathways. 

 
 
 
 
 
 
 Local clinical leaders are working with Patient & Public Voice (PPV) and Expert by 
Experience (EbyE) representatives, regional colleagues, new provider collaboratives 
clinical, operational and commissioning leads, alongside NHSE Provider 
Collaboratives and MH Policy teams to support the development of new care 
models, to address the significant pressures, capacity and access issues across the 
system and reduce the reliance on inpatient beds in line with the evidence base for 
Eating Disorders.  

The national mental health specialised commissioning team is supporting regional 
teams and wider eating disorder service transformation through specialist expert 
advice provided by NHSE Clinical Reference Groups and National Programme of 
Care for Specialised Mental Health. Additionally, a national inpatient Demand & 
Capacity exercise has recently been undertaken and findings from this will be used 
to support the reconfiguration of existing eating disorder beds and the development 
of whole patient pathways through Provider Collaboratives and ICS as required by 
the NHS Long Term Plan. 

Impact of COVID-19 Pandemic 
Eating disorder services have been working hard to minimise disruptions in care due 
to the COVID-19 pandemic by using digital solutions where appropriate, or COVID-
safe face-to-face appointments when needed. An additional £58m also has been 
allocated to support community mental health services responding to COVID, 
including a focus on accelerating transformation across eating disorder pathways, 
with a focus on early intervention models and close working with voluntary and 
community sector partners. 

Inpatient access remains somewhat impacted by Covid-19 due to the number of 
acute presentations seen across regions as the country came out of the first 
lockdown. Lessons learned from the first lockdown have been embedded in 
restoration and recovery plans for adult eating disorders inpatient services to ensure 
future proofing of service delivery as the pandemic continues and services are 
transformed in line with national guidance.  

Patients who require admission to inpatient services are to be supported with 
intensive community care and treatment programmes while awaiting admission. 
There is also a broader range of AED community services which are locally 
commissioned by CCGs. These local arrangements vary across England and are 
primarily aimed at addressing the needs of patients with disordered eating which 
does not require admission to an inpatient setting or need the highly intensive 
treatments offered by the NHSE commissioned specialist services.  

While locally commissioned arrangements vary, in all cases patients with severe 
eating disorders or considered to be at high risk, will be referred directly to the 
specialist services commissioned by NHSE for assessment and or 
admission/treatment. 

Once again, I’d like to express my deepest sympathies to Charlotte’s family and I 
hope the above response from NHS England has gone some way to allaying the 
concerns raised in your Regulation 28 report.  

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

Yours sincerely, 

Medical Director for Professional Leadership and Clinical Effectiveness 

Lead Medical Director for Covid-19 Medical Workforce Cell 

NHS England & NHS Improvement