Nichola Lomax

Bundle Index 

SECTION A – Evidence 

Document 

Date 

Author 

Pages 

Signed Regulation 28 

20/12/2021 

A1 – A6 

Reg 28 response from 
Gillian Keegan 

29/07/2022 

A7 – A10 

Reg 28 response - RCPsych   04/02/2022 

A11 – A17 

Reg 28 response - NHSEI 

18/02/2022 

A18 – A22 

Reg 28 response - AOMRC 

11/02/2022 

A23 – A24 

Reg 28 response - NCA 

14/02/2022 

A25 – A28 

Reg 28 update - NCA 

12/08/2022 

A29 – A29 

Reg 28 Response -GMMH 

13/04/2022 

A30 – A33 

Reg 28 response - Priory 

25/02/2022 

A34 – A36 

Reg 28 response - NHS HE 

15/02/2022 

A37 – A39

 Reg 28 response - Bury 
CCG 

03/02/2022 

A40 – A43 

Reg 28 response - GMCA 

11/02/2022 

A44 – A49 

~S1
|

~S3
|

~S4
|

~S5
|

~S6
|

~S7
|

~S8
|

~S9
|

~S1
0|

~S1
1|

~S1
2|

~S1
3|

~S1
4|

~E

~E

~E

~E

~E

~E

~E

~E

~E

~E

~E

~E

~E

 
 
 From Gillian Keegan MP 
Minister of State for Care and Mental Health 
39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

25 July 2022 

Joanne Kearsley 
Senior Coroner 
HM Coroners Court 
Newgate House 
Newgate 
Rochdale 
OL16 1AT 

Dear Ms Kearsley, 

Thank you for your correspondence of 17 December 2021 to the Secretary of State 
for Health and Social Care, Sajid Javid, regarding the tragic death of Nichola Lomax. 

I extend my deepest condolences to Ms Lomax’s family and friends. I, the Department, 
and health bodies, at both a national and local level, take the Report’s concerns very 
seriously.  Improving eating  disorders  services  is a  key  priority  for the  Government 
and a vital part of our work to improve mental health services. 

Your report raises important concerns regarding adult eating disorder treatment and 
shared  learning  across  the  health  system.  Following  the  Parliamentary  and  Health 
Service Ombudsman (PHSO) report “Ignoring the alarms: how NHS eating disorder 
services are failing patients”1, regarding the tragic death of Averil Hart, the Department 
of Health and Social Care has been working with NHS England and NHS Improvement 
(NHSEI), Health Education England (HEE), the General Medical Council, the National 
Institute for Health and Care Excellence and the Royal College of Psychiatrists through 
a  delivery group to continue  to address  the recommendations.  We  understand the 
importance of working with such partners and remain committed to continue working 
to push forward improvements for this vulnerable group. 

Regarding  the  matter  of  concern  that  you  raise  related  to  inadequate  training  of 
medical professionals regarding eating disorders - doctors should have the necessary 
knowledge and experience of mental health 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.  The 
Department  will  continue  to  support  and  assure  this  work  to  progress  against  key 
actions, including ensuring better awareness of eating disorder training and continuing 
professional development.  We recognise the work of external partners, such as Beat, 
to push forward better training in medical courses, and the necessary focus of Eating 

1 https://www.ombudsman.org.uk/sites/default/files/page/ACCESSIBILE%20PDF%20-
%20Anorexia%20Report.pdf 

1 

A7 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Disorder awareness week this year on this issue, which we will continue to support as 
a Department. 

Eating disorders have some of the highest mortality rates of any mental health disorder 
and appropriate monitoring of anorexia nervosa patients by primary or secondary care 
providers is vital.  Under the NHS Long Term Plan, the Department is 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. 

This investment has already begun, with all Integrated Care Systems (ICSs) receiving 
funding  to  transform  adult  community  mental  health  services,  including  eating 
disorders, with the expectation that all ICS will have transformed services in place by 
2023/24. In 2021/22, 33 ICSs are transforming adult eating disorder services, with the 
remainder  due  to  begin  transformation  of  services  in  2022/23.  In  their  response, 
NHSEI  have  set  out  the  importance  of  this  funding  and  adherence  to  adult  eating 
disorder patient care guidance, to ensure the highest standards of care. NHSEI’s work 
continues to highlight to systems the importance of early intervention services, as well 
as ongoing medical monitoring and ensuring access to care in the right place, and at 
the right time. 

The Department recognises that NHS eating disorder services are facing increased 
demand.  For  example,  the  number  of  children  and  young  people  entering  urgent 
treatment for an eating disorder increased by 73% in financial year 2020/21 compared 
to 2019/20 according to NHS data.  Recognising this increase in demand, on 27 March 
2021 the Department published its Mental Health Recovery Action Plan, backed by an 
additional £500 million of targeted investment, to ensure that right support is in place 
for this financial year. 

As  part  of  this  funding  £79  million  is  being  used  to  significantly  expand  children’s 
mental health services, including allowing 2,000 more children and young people to 
access eating disorder services. £58 million has been 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. 

In addition, the Department is developing a new long term, cross-government Mental 
Health Strategy in the coming year.  The Government will launch a public discussion 
paper this year to  inform  the development  of  this strategy.  This will set  us  up  for a 
wide-ranging and ambitious conversation about potential solutions to improve mental 
health and wellbeing. 

This  case  is  shocking  and  is  a  tragedy,  and  something  taken  very  seriously  in  the 
Greater Manchester healthcare system, hence the collaborative system response and 
approach  to  improving  services  moving  forward.  This  should  and  will  be  a  “never 
event” in the Greater Manchester ICS’s developing quality and safety model under the 
new  Integrated  Care  Board  (ICB).  Unfortunately,  cases  like  this  have  been  seen 

2 

A8 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 nationally as well, from which all regions must learn lessons and share good practice. 
All three ICS regions in the North West are part of the eating disorder lead provider 
collaborative and this will strengthen learning and development across the area too. 

This  case  has  accelerated  the  mobilisation  of  the  dedicated  Greater  Manchester 
Mental Health  system quality  and  safety group,  which will be  a  system  wide  panel, 
including - social care, primary care, acute care, mental health, voluntary, community 
and social enterprise, all blue light services and service users and carers, and will be 
chaired by the executive medical lead for mental health. This panel will report to the 
Greater  Manchester  system  quality  and  safety  board,  chaired  by  the  chief  Medical 
Director  and  supported  by  the  Chief  Nurse,  and  accountability  for  monitoring  and 
quality improvement will be under the ICB (Chief Medical Director and Chief Nurse) 
supported by the Executive Medical lead for Mental Health and the wider clinical and 
care professional leadership group. 

There has been a year on year rise in eating disorders and a particular rise through 
the  pandemic  across  all  ages,  especially  in  young  people  and  young  adults. 
Nationally, the launch of MEED2 in May this year will see the most significant quality 
improvement in eating disorders in the last 5 years in addition to the transformation of 
young  people’s  eating  disorder  services.  This  is  the  “Management  of  medical 
emergencies  in  eating  disorders”  guidance  developed  by  The  Royal  College  of 
Psychiatrists  (2020) and  now  embedded  in  the  NICE  guidance  for  eating  disorders 
assessment, treatment and management. This is based on the previous MARSIPAN3 
and Junior MARSIPAN guidelines for managing severe anorexia nervosa, but MEED 
is all ages and all eating disorders with a shared language and risk assessment tool 
that can be used by all clinical and care professionals across the system. This includes 
social care colleagues to strengthen the safeguarding support for vulnerable adults. 
This tool is akin to the NEWS 2 tool, developed by The Royal College of Physicians 
for risk assessment and triage for those presenting with physical health illnesses and 
now a shared language across the urgent and emergency care system. 

The traffic light system in MEED has been endorsed by NHSE/I and is being rolled out 
across the system in Greater Manchester and nationally now so that, like NEWS 2, we 
can see significant improvement in risk assessment and triage.  There will also be a 
requirement for all ICSs to have a formally established whole-system MEED group, 
which we have started for young people and are now starting for adults, with a link 
across the two to ensure the transitions are also addressed.  Greater Manchester have 
also  accelerated  the  review  of  the  whole  adult  eating  disorders  pathway,  including 
revised protocols with our independent sector providers and greater collaboration with 
the voluntary, community and social enterprise sector providing both prevention and 
recovery support as well as carer support.  The MEED groups will be responsible for 
training  rollout  with  resource  support  from  the  Mental  Health  programme  and  our 
provider collaboratives which will be monitored through the system quality and safety 
group at a Greater Manchester level. 

2 https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-
reports/2022-college-reports/cr233 
3 The Management of Really Sick Patients with Anorexia Nervosa 

3 

A9 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 I  hope  this  reply  helps  to  reassure  you  that  partners  across  the  health  system  are 
working to make improvements as a result of this report to prevent this happening in 
future.  The  Department  takes  the  matters  raised  in  this  report  seriously  and  will 
continue to engage on progress via the PHSO Delivery Group, and through the new 
mental health strategy. 

I hope this response is helpful. 

GILLIAN KEEGAN 

4 

A10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Joanne Kearsley, Senior Coroner for Coroner area of 
Manchester North 

Dear Ms Kearsley 

Royal College of Psychiatrists response to Coroner’s Report into 
the death of Nichola Lomax 

Purpose of response 

To respond to those aspects of the Coroner’s Report into the tragic death 
of Nichola Lomax that are relevant to the Royal College of Psychiatrists, in 
particular to what is referred to as the “MARSIPAN” guidelines in the 
Report. The updated guidance referred to in this document will have a 
different title (Medical Emergencies in Eating Disorders) but given the 
language in the Report, we are using “MARSIPAN” for ease of reference in 
this response. 

We would first of all though like to take the opportunity to extend our 
sincere and deepest sympathies to Nichola’s family, friends and all who 
cared for her. 

Background 

The Royal College of Psychiatrists is the professional medical body 
responsible for supporting psychiatrists throughout their careers, from 
training through to retirement, and in setting and raising standards of 
psychiatry in the United Kingdom. The College aims to improve the 
outcomes of people with mental illness, and the mental health of 
individuals, their families and communities. In order to achieve this, the 
College sets standards and promotes excellence in psychiatry; leads, 
represents and supports psychiatrists; improves the scientific 
understanding of mental illness; works with and advocates for patients, 
carers, and their organisations. Nationally and internationally, the College 
has a vital role in representing the expertise of the psychiatric profession 
to governments and other agencies. 

While these are extremely tragic circumstances on which to have to 
communicate, we hope that the information we provide in this note 
responds to the issues you raise that are relevant to the College, and that 
this may contribute to minimising the risk of similar events occurring in 

A11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the future. If you have any questions or would like to discuss any aspect 
of our response, please do not hesitate to contact us at 

This response has been developed with the support of the College’s Eating 
Disorder Faculty, which is the part of the organisation that brings 
together psychiatrists working in eating disorders across the age 
range. It aims to secure the best outcome for people with eating 
disorders by: 

  promoting excellent services, 
  supporting the prevention of eating disorders, 
  ensuring prompt treatment to achieve higher recovery rates and 

prevent complications, 
improving medical training in eating disorders, 

 
  promoting quality and research, 
  setting standards and 
  being the voice of eating disorder psychiatry. 

“MARSIPAN" Guidelines 

The College role is one to influence, support and advise, and we do 
not have any statutory responsibility. For example, in light of the 
reference to the “MARSIPAN” guidelines in the Report, we have no 
formal levers by which we can assure ourselves of compliance with it, 
including the provision of the necessary funding and associated 
workforce resources to implement it. 

That said, the College and its Eating Disorder Faculty have 
undertaken significant activity that seeks to improve services through 
mechanisms such as evidence-based guidance and training. 

The impetus for publishing the “MARSIPAN” guidelines in 2010 was the 
tragic death of a young woman in hospital in 2008 It was developed in 
collaboration with the Royal College of Physicians and the Royal College of 
Pathologists, with a focus on ensuring the safe management of 
emergencies in anorexia nervosa. The document was published on the 
RCPsych website, and a number of conferences and training events were 
organised by the College to promote its dissemination. 

As that original document only applied to adult care, Junior MARSIPAN 
guidance was developed in 2012, and in 2014, the adult document 
originally published in 2010 was revised. Owing to the insufficiency of 
randomised controlled trials in the field, the MARSIPAN guidance was 
initially based on expert consensus of best practice, rather than the 

A12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 methods required by the NICE guidelines. However, it was quoted in the 
NICE Eating Disorder guidelines (NICE, 2017) in the context of the 
management of refeeding in hospitals. It is also referred to in the NHSE 
Commissioning guidance for specialist inpatient and community services. 
(National Collaborating Centre for Mental Health, 2019; NHS England, 
2013). 

Although the guidance was widely accepted by specialist services 
(particularly CAMHS eating disorder services and paediatrics), the College 
identified and acknowledged that many acute trusts did not implement it 
fully and consistently, which corresponds with your findings in this case. 
When exploring the reasons for this, we understood that the barriers to 
implementation included: 




 the lack of targeted funding and training of the workforce 
 the methodology and impact of RCPsych College Reports do not 
carry the same weight as the NICE guidelines 

  an overlap with the NICE Nutrition Support for Adults guidelines 

(NICE, 2006), which acute trusts follow (even though that excludes 
eating disorders). 

To address these issues, the College agreed on a major revision of 
MARSIPAN in 2019.This work is now close to completion and is due to be 
published in the first half of 2022. The main aims of the revision are to 
tackle the barriers identified previously to its implementation (to achieve 
wider acceptance and dissemination of these guidelines), and to widen 
the scope to include all eating disorders across the age range. 

The revision has been supported by the College’s National Collaborative 
Centre for Mental Health, and it has been developed via a robust 
methodology. Wide consultation on the draft has been taken forward with 
internal and external stakeholders, including other Faculties within the 
College, such as Child and Adolescent, General Adult and Liaison. We 
have and are still actively engaging with other medical Royal Colleges, the 
BDA, other charities such as BEAT, and experts by experience. We will be 
seeking endorsement from external stakeholders, including the Academy 
of Medical Royal Colleges (AOMRC). This process is important to ensure 
that clinicians, not just psychiatrists understand that they have a role to 
play in identifying and tackling eating disorders. 

The College will also work with relevant stakeholders, such as HEE, 
AOMRC, RCGPs, RCPCH, RCEM, RCP and our College Curriculum 
committee to ensure that the guidelines are embedded in relevant 
undergraduate and postgraduate training materials. 

A13 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 However, implementation of the guidance will be dependent not just 
on dissemination but also on the leverage and resources that can and 
must emerge from those who are responsible for it. Therefore, we 
are also in discussion with NHSE/I to seek their active support and 
this engagement has been positive and we look forward to further 
work with and by them to help embed these new guidelines across 
the country. 

Training 

As reflected earlier in our response, to maximise the impact of these 
guidelines we will need to see a ramping up of the training and expansion 
of the workforce in mental health and beyond. 

In terms of training, as Eating Disorder psychiatry is not a GMC 
recognised subspecialty, we have made significant efforts to address this 
gap. Following a national survey showing that most medical doctors 
receive fewer than 2 hours of training about eating disorders (Ayton and 
Ibrahim, 2018) and the PHSO report (Parliamentary and Health Service 
Ombudsman, 2017), we have been working with the GMC, HEE, Beat, 
NHSE PHSO implementation group, the RCPsych Curriculum committee, 
and examination panels. A summary of progress so far is shown below: 

1.  We published a Position Statement ‘Improving Core Skills and 

Competence in Risk Assessment and Management of People with 
Eating Disorders: What all Doctors Need to Know’, which provides a 
blueprint for training at all levels (Ayton et al., 2020) The key 
messages included: 
  There is an imperative to improve training in eating disorders for 
all undergraduate doctors in the interface between physical and 
mental health, alongside a greater emphasis on mental health in 
undergraduate training. 

  Postgraduate training in all specialties should include nutritional 

and psychological aspects of eating disorders, including 
recognition of severe malnutrition as a medical emergency, 
regardless of aetiology. 

  Leadership competencies should emphasise the need for all 
doctors to create and manage safe patient pathways across 
complex systems. 

2.  In collaboration with HEE and BEAT we developed online training 

materials about eating disorders for medical students and 
foundation trainees, which are freely available. 

A14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  With funding and support from the GMC, we will be working with 
AOMRC on developing shared curricula about eating disorders for 
postgraduate training across relevant Royal Colleges. This work has 
started in January 2022. 

4.  The College Curriculum, Education and Training Committees are 
exploring how they can strengthen core and higher training in 
eating disorders. This work is still ongoing. 

5.  The RCPsych received funding from HEE to develop eating disorders 
credentialing, which will improve the standards of training for those 
who wish to specialise in the field. This work will be starting in the 
next few months. 

Funding and Workforce 

The implementation of best practice guidelines is dependent on 
appropriate funding and the development of the workforce, which we look 
to the Government to provide and support. There has been some 
welcome progress in resources in the recent past, particularly in relation 
to children and young people but to maximise the impact of the soon to 
be published guidelines this needs to be accelerated and expanded, in 
particular a larger focus on adults with eating disorders is crucial. 

In terms of workforce developments, the data shows the scale of what 
needs to be done. According to the 2021 RCPsych Census, there are only 
97 substantive consultants working in the field in the UK, and half of them 
are part time. Vacancy rates were recorded as 12%. Approximately half of 
the consultants work in independent specialist units, such as the Priory, 
which are not well integrated into local health care systems, and this may 
in some part explain the confusion and poor communication highlighted in 
your report. 

These numbers are in stark contrast with the 23,954 patients needing 
hospitalisation for a primary or secondary diagnosis of eating disorder in 
2020/21(NHS Digital, 2021). Many NHS specialist eating disorder services 
are running without or have minimal consultant psychiatrist input, a 
problem that was highlighted in a recent Reg 28 Report (Horstead, 2021). 
If there are insufficient specialists to help manage these patients and to 
advise colleagues who are unfamiliar with the condition, there remains 
the risk of similar tragedies in the future. 

It is essential that all eating disorder services employ a consultant 
psychiatrist as part of specialist multidisciplinary teams, as they are the 
only professional group who have training both in the physical and mental 

A15 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 health aspects of eating disorders and assessing and managing complex 
cases. Consultants also have important roles in training, research and 
advising non-specialist services. The requirement for employing 
consultant psychiatrists is clearly specified in the NHSE Commissioning 
guidance and in the RCPsych Quality Network for Eating Disorders (QED), 
however, many NHS services have insufficient or no psychiatric input, and 
addressing this shortfall is essential for the prevention of future deaths. 
This will require an urgent expansion of training and consultant posts as 
part of the forthcoming investment into eating disorder services. 

I hope you find this helpful and please let me know if I can be of any 
further help. 

Yours sincerely, 

RCPsych Registrar 

RcPsych ED Faculty Chair 

Ayton, A., & Ibrahim, A. (2018). Does UK medical education provide doctors with sufficient skills and 
knowledge to manage patients with eating disorders safely? Postgrad Med J, 94(1113), 374-
380. doi:10.1136/postgradmedj-2018-135658 

Ayton, A., Nicholls, D., & Robinson, P. (2020). Improving core skills and competence in risk 

assessment and management of people with eating disorders: What all doctors need to 
know. Retrieved from https://www.rcpsych.ac.uk/docs/default-source/improving-
care/better-mh-policy/position-statements/ps04_20.pdf?sfvrsn=6c927307_2 

Horstead, S. (2021). Regulation 28: Report to Prevent Future Deaths. Retrieved from Cambridge: 
https://www.judiciary.uk/wp-content/uploads/2021/03/Averil-Hart-2021-0058-
Redacted.pdf 

House of Commons Public Administration and Constitutional Affairs Committee. (2019). Ignoring the 
Alarms follow-up: Too many avoidable deaths from eating disorders. Retrieved from London: 
https://publications.parliament.uk/pa/cm201719/cmselect/cmpubadm/855/855.pdf 
National Collaborating Centre for Mental Health. (2019). Adult Eating Disorders: Community, 
Inpatient and Intensive Day Patient Care Guidance for commissioners and providers. 
Retrieved from London: https://www.england.nhs.uk/wp-content/uploads/2019/08/aed-
guidance.pdf 

NHS Digital. (2021, 2021). Hospital admissions with a primary or secondary diagnosis of eating 
disorders. Retrieved from https://digital.nhs.uk/data-and-information/supplementary-
information/2021/hospital-admissions-with-a-primary-or-secondary-diagnosis-of-eating-
disorders-2019-20-to-2020-21 

A16 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 NHS England. (2013). NHS Standard Contract for Specialised Eating Disorders (adults). Retrieved 

from https://www.england.nhs.uk/commissioning/wp-
content/uploads/sites/12/2014/12/c01-spec-eat-dis-1214.pdf 

NICE. (2006). Nutrition support for adults: oral nutrition support, enteral tube feeding and 

parenteral nutrition. In. 

NICE. (2017). NICE Guidance 69. Eating Disorders: Recognition and treatment. 
Parliamentary and Health Service Ombudsman. (2017). Ignoring the alarms: How NHS eating 

disorder services are failing patients. Retrieved from London: 
https://www.ombudsman.org.uk/sites/default/files/page/ACCESSIBILE%20PDF%20-
%20Anorexia%20Report.pdf 

A17 
 Ms J Kearsley, HM Senior Coroner 
H M Coroner’s Office – Manchester North 
Floor 2&3 Newgate House 
Newgate 
Rochdale 
OL16 1AT 

National Medical Director and Interim 
Chief Executive, NHS Improvement 
Skipton House 
80 London Road 
London 
SE1 6LH 

18 February 2022 

Dear Ms Kearsley, 

Re: Regulation 28 Report to Prevent Future Deaths – Nichola Jane Lomax who 
died on 3 August 2020 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4 
December 2021 concerning the death of Nichola Jane Lomax on 3 August 2020. I 
would like to express my deep condolences to Nichola’s family. 

I note the inquest concluded Nichola‘s death was a result of the physical 
complications of the mental disorder anorexia nervosa, contributed to by neglect. 

Following the inquest, you raised concerns in your Report regarding: 

• 

Inadequate training of doctors and other medical professionals re eating 
disorders; 

•  Accessing specialist advice; 
•  Community monitoring of patients with an eating disorder; and 
•  Lack of recognition of the need to investigate. 

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 North West region. 

Within NHS England and Improvement (NHSEI), we recognise that more needs to 
be done to support those with severe mental health problems, including eating 
disorders. The NHS Long Term Plan sets out an ambition to give adults and older 
adults with severe mental illness, including adult eating disorders, greater choice and 
control over their care and support them to live well in their communities. This 
programme also requires that, by 2023/24, all ICSs establish or expand dedicated 
community-based adult eating disorder services in line with published NHSEI 
guidance on improving community-based care for adults & older adults with eating 

NHS England and NHS Improvement 

A18 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 disorders.1 By 2023/24 just under £1 billion of additional funding per year will be 
invested in community mental health services, including eating disorders. 

Since April 2021 all ICSs have received funding to transform their adult community 
mental health services, including eating disorders. In 2021/22, 33 ICSs are 
transforming adult eating disorder services, with the remainder due to begin 
transformation of services in 2022/23. We are supporting this work with a significant 
training programme to upskill staff, as well as further activity to support key aspects 
of transformation such as imbedding early intervention models and improving 
connections with Primary Care. 

Alongside community mental health transformation, there is also a cross-
Government programme of activity to address wider issues with eating disorders, in 
response to recommendations for action made by the Parliamentary and Health 
Service Ombudsman’s 2017 report “Ignoring the Alarms: How NHS eating disorder 
services are failing patients” and follow up 2019 report. As part of this work, NHSEI 
are currently developing the specification for a national all-ages clinical audit of 
eating disorder services, which will review the quality of care against NICE standards 
and seek to drive improvement of the identification and appropriate management of 
Eating Disorders and the quality and consistency of services. 

I will now respond to each of your concerns in turn: 

1.  Inadequate training of doctors and other medical professionals re eating 

disorders 

As part of community mental health transformation, NHSEI are working in 
partnership with Health Education England (HEE) on a number of different training 
courses for staff supporting individuals with eating disorders. These include “Whole 
Team Training for Eating Disorders” and “Eating disorder training for medical 
students, trainees and doctors” (commissioned with the VCS organisation Beat), 
which both promote use of  MARSIPAN guidelines. HEE are also commissioning 
Beat to produce targeted eating disorder training for staff working in acute settings in 
2022, which will include reference to MARSIPAN guidelines. 

The Royal College of Psychiatrists is currently finalising “Guidance on Recognising 
and Managing Medical Emergencies in Eating Disorders” (replacing MARSIPAN and 
Junior MARSIPAN). We are in discussion with the College about how best to 
promote and embed this new guidance across all relevant clinical settings (including 
potential dissemination by liaison psychiatrists who work in general acute settings), 
and will also ensure training and guidance is updated to promote it. This guidance 
will be supported by all the Royal Colleges so it will be clear this product is relevant 
to staff outside of psychiatry. 

This concern also reflects a wider challenge with the levels of training that doctors 
and other medical professionals receive on mental health. We believe this is 
imperative to support parity of esteem and improve patient care, particularly for 

1 Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care: Guidance for 
commissioners and providers (england.nhs.uk) 

A19 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 eating disorders. 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 North West actions underway 

Through the development of a Lead Provider Collaborative model for specialist 
Eating Disorder services, Cheshire & Wirral Partnership NHS Foundation Trust as 
lead provider for Specialised Eating Disorder services in the North West, are 
developing approaches to strengthen system leadership in the field of Eating 
Disorders. As part of this work, they have a number of priorities including the 
promulgation across the region of good practice in ED care; improving the clinical 
pathway for patients with Eating Disorders; the development of consistent protocols 
for the management of physical health risks of eating disorders in the community; 
and identification of workforce gaps in community services.   Both the promulgation 
of best practice and the development of consistent protocols will have a positive 
impact on education and practice around Eating Disorder clinical management. 

2.  Accessing Specialist Advice 

In 2019 NHS England and Improvement issued “Adult Eating Disorders: Community, 
Inpatient and Intensive Day Patient Care” national guidance for commissioners and 
providers. This highlights that one of the key functions of care for a comprehensive 
eating disorder service is to “offer advice, support and consultation to other services 
involved in a person’s care”.2 Providers and commissioners are encouraged 
to develop pathways and protocols in line with this advice. 

The introduction of mental health practitioners in Primary Care Networks (PCNs) 
should also enable easier access to specialist services. These staff are based in 
primary care but employed by mental health trusts, to support an integrated care 
pathway for people with severe mental illness, including eating disorders. 

Additional North West actions underway 

NHS bodies in Greater Manchester are committed to developing a model of 
community Eating Disorder services which fits that described in NHS England’s 2019 
guidance.  This model, once in place, will be able to be perform the role of primary 
source of information and advice for all healthcare services that come into contact 
with patients with an Eating Disorder.  

In addition, NHS England will work with the Specialised Eating Disorder services in 
the North West (CWP and The Priory) to clarify the expectation outlined in section 
2.5 of the national service specification for Specialised Eating Disorder services 
around the scope of advice and guidance to acute medical and to psychiatric wards 
that this should include. 

2 Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care: Guidance for 
commissioners and providers (england.nhs.uk) (p.8) 

A20 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  Community Monitoring of patients with an Eating Disorder 

NHSEI’s national guidance sets out a clear expectation that community eating 
disorder services develop integrated pathways with primary care and where 
responsibility for medical monitoring sits. The guidance is clear that that “Medical 
monitoring needs to be based on local medical monitoring agreements clearly 
established across the community eating disorder service and primary care network, 
with one consistent protocol agreed on by local commissioners. The protocol should 
be developed in collaboration with primary care services and clearly outline the 
responsibilities for each service (Table 2). A shared care pathway for medical 
monitoring should be produced.” 

The guidance further sets out “When responsibility for medical monitoring is 
assumed by primary care, the limitations of this need to be recognised and mitigated. 
The CED service should be accessible to provide specialist consultation to primary 
care to ensure results are interpreted correctly, regardless of whether a person is 
currently engaging with the CED service. To ensure that the CED service has 
capacity to reliably provide this, opportunities for upskilling other staff members 
(such as nurses) should be explored. A CED service that is accessible for 
consultation will facilitate GPs’ safe acceptance of discharges from the CED service 
and reduce demand on the CED service’s resources” 

We are committed to ensuring a more integrated service across primary and 
secondary care for people with severe mental illnesses, including eating disorders. 
In order to receive system development funds for the expansion of adult community 
eating disorder services, when developing funding bids systems 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” and 21/22 
Mental Health Delivery Plan highlighted that systems should “ensure AED pathways 
have medical monitoring protocols in place with primary care”. 

Working with HEE, we have also commissioned eating disorder charity Beat to 
develop training to support staff in Primary Care which will include specific training 
on medical monitoring. NHSEI are currently exploring what additional resources 
could be developed to better support and engage Primary Care. 

I noted earlier in this response work to introduce Mental Health Practitioners in 
Primary Care. 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. 

A21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
    
 
 Additional North West actions underway 

NHS bodies in Greater Manchester are committed to developing a model of 
community Eating Disorder services which fits that described in NHS England’s 2019 
guidance.  This model, once in place, will be in a position to undertake the medical 
monitoring of high risk and non-adherent patients whilst also offering specialist 
consultation to primary care for low-moderate risk patients and those discharged 
from the community Eating Disorder services. 

4.  Lack of Recognition of the need to Investigate 

The National Medical Examiner is also concerned about deaths of people with eating 
disorders.  In late 2021, the National Medical Examiner’s team proposed a round 
table discussion with subject matter experts and stakeholders, including 
representatives from the Chief Coroner’s office, with a view to publishing guidance 
for medical examiners through the National Medical Examiner’s series of Good 
Practice papers.  The round table discussion to inform this paper is due to take place 
in February 2022, with publication expected later in 2022. 

The medical examiner system has been implemented at acute trusts on a non-
statutory basis.  Most trusts established medical examiner offices during 2020, after 
DHSC confirmed funding details in late December 2019.  In the year to September 
2021 (the most recent figures available) NHS trusts reported that medical examiners 
provided independent scrutiny of more than 185,000 deaths in England.  The 
National Medical Examiner asked the regional medical examiner for the North West 
to confirm what involvement, if any, medical examiners had after the death of 
Nichola Jane Lomax.  The lead medical examiner at Northern Care Alliance 
Foundation Trust confirmed that the medical examiner office was established after 
August 2020, and therefore, medical examiners were not involved in reviewing the 
circumstances of Ms Lomax’s death. 

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 & 
Interim Chief Executive, NHSI 

A22 
 
 
   
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Academy of Medical 

Royal Colleges 

10 Dallington Street 

London, EC1V 0DB 

Academy of Medical Royal Colleges 

Regulation 28 

A23 
 
 
 
 
 
 
 
 
 
 
 
 • 

• 

Academy of Medical Royal Colleges 

Regulation 28 

A24 
 
 
 
 
 
 
 A25 A26 A27 A28 Ms J Kearsley 
Senior Coroner 
Newgate House 
Newgate 
Rochdale 

Friday 12th  August 2022 

Dear Ms Kearsley 

Popham Centre 
Fairfield District General Hospital 
Bury 

I write on behalf of the Northern Care Alliance NHS Foundation Trust to update you on developments in 
respect of action taken to improve services following the tragic death of Nichola Lomax and the inquest into 
her death heard in November 2021. 

During the inquest into Ms Lomax’s death, lesson learning evidence was provided to the Court by 

, detailing the steps taken since the incident and lessons learned by the Trust to effect change and 

improve services offered to patients presenting with an eating disorder. A full action plan was put in place in 
response to the Trust’s investigation. It was identified during the Trust’s investigation that prior to Ms Lomax’s 
death, dissemination, and awareness of the Management of Really Sick Patients with Anorexia (“MARSIPAN”) 
guidelines in place at the time was sporadic across the NCA’s care organisations. The Trust undertook 
immediate steps whilst the investigation was ongoing to raise awareness of the guidelines. 

A further update on the Trust’s continued action to improve services and addressing your specific areas of 
concern raised in the Regulation 28 report issued following in the inquest was provided on 11 February 2022. 
Since this time, updated guidance around the recognition and management for Medical Emergencies in Eating 
Disorders (“MEED”) was released by the Royal College of Psychiatrists in May 2022. This replaces the 
previous MARSIPAN guidance that was in place at the time of Ms Lomax’s death. 
The Trust is now taking steps to update all applicable guidance documents and policies to reflect the current 
MEED guidance. An NCA-wide steering group is in development to agree a NCA level MEED Quick Reference 
Guide.  This will be monitored and progressed through system partners who will discuss and confirm 
governance arrangements under the Integrated Care System. 

It was described in the Trust’s regulation 28 response that engagement was being sought for a training video 
and formulating a plan for its development. I would like to advise you that this action has been superseded as 
a result of the updated MEED guidance. In response to MEED, a national app has been developed which 
includes a full suite of guidance and information with videos and support. The Trust is now working to roll the 
app out and raise awareness of this across all Care Organisations alongside updating associated policies and 
guidance.  The first Steering Group is scheduled for early September.  We will of course keep you appraised 
of organisational developments in due course. 

Please do not hesitate to contact me if you have any questions or require any further information. 

Yours sincerely, 

Associate Director of Patient Safety 

A29 
 
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A30 A31 A32 A34 A35 A36 Joanne Kearsley 
Senior Coroner for the Coroner area 
of Manchester North 

Directorate of Education & Quality 
2nd  Floor, Stewart House 
32 Russell Square 
London WC1B 5DN 

Business Coordinator: 

Email: 

14th February 2022 

Dear Joanne Kearsley, 

RE: Nichola Jane Lomax – Regulation 28 Report 

I write in response to your report of 17 December 2021 made under the Coroners 
(Investigations) Regulations 2013.  Please may I start by offering my sincere 
condolences to Nichola Lomax’s family following her death. 

Your report raises concerns regarding the care that Nichola Lomax received, together 
with the training of doctors and other medical professionals in relation to mental health 
conditions and eating disorders.   Your report also highlighted concerns around the 
knowledge and awareness of health professionals; specifically highlighting what 
appeared to be a lack of knowledge of the Management of Really Sick Patients with 
Anorexia Nervosa guidance (MARSIPAN).  We note that Health Education England 
(HEE) has been identified as having a duty to respond and the report has also been 
sent to a number of bodies including: The Secretary of State for Health and Social 
Care; the Chair of the Faculty of Eating Disorders Royal College of Psychiatrists; the 
Chief Executive Officer of NHS England; The Chief Executive of the Academy of 
Medical Royal Colleges; together with local health agencies and providers who were 
involved in the care of Nichola Lomax prior to her death. 

To respond to your concerns, I will first clarify HEE’s role and in the education and 
training of the medical, nursing and health workforce.  HEE is a non-departmental 
public body accountable to the Secretary of State and Parliament.  We are part of the 
NHS and work with partners to plan, recruit, educate and train the health workforce. 
Though HEE serves the people of England by educating, training and developing 
healthcare professionals, we do not have responsibility for the design and delivery of 
undergraduate medical education. Each individual medical school sets its own 
undergraduate medical curriculum.  Additionally in relation to postgraduate medical 

A37 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 education, the various curricula for postgraduate specialty training are set by individual 
Medical Royal Colleges against standards set by the General Medical Council. 

Whilst the curriculum for medical education does not mandate how Foundation doctors 
learn about specific conditions, as different learners and educators will have preferred 
styles within their own setting. The 2021 Foundation Programme curriculum includes 
an explicit statement around parity between physical and mental health. Foundation 
doctors are now expected to learn about mental health issues much more than in the 
past.  In addition, the MARSIPAN guidelines have been presented to Foundation 
School Directors and there has been other discussion on learning and eating disorders 
within the Foundation Programme. 

As part of reviewing this case, we have shared your report with colleagues here within 
HEE, including our Dean with lead responsibility for Mental Health.  Together with our 
Mental Health Programme, the UK Foundation Programme Office and our Deputy 
Chief Nurse.  We believe that your report provides important learning and both the 
circumstances and concerns in your report are vitally important in demonstrating the 
need to increase awareness and understanding of the training and clinical guidance 
already available to practitioners. 

I should also highlight some of the work that HEE has been involved in, either to 
support better awareness or strengthen professional practice through continuing 
professional development. This includes a new teaching package on eating disorders 
for foundation programmes that has been developed by the charity Beat Eating 
Disorder, in collaboration with Health Education England and the Royal College of 
Psychiatrists, and with the support of the General Medical Council. This training was 
created in response to the Parliamentary Health Service Ombudsman investigation 
into avoidable deaths from eating disorders and has been written by experienced 
clinical trainers and developed with input from senior clinicians, medical students, 
people with lived experience, and advisors from the General Medical Council and 
Health Education England.  Further information on this training can be found here: 
https://www.e-lfh.org.uk/programmes/eating-disorders-training-for-medical-students-
and-foundation-doctors/ 

Beating Eating Disorder has previously endorsed MARSIPAN and though HEE is not a 
member of the MARSIPAN working group, we have circulated information on their 
work and guidance. We understand that they are working towards issuing revised 
guidance in 2022 and we will then seek to ensure this is disseminated to relevant 
teams and colleagues here at HEE. 

HEE is also working with NHSE/I and a range of stakeholders to continually enhance 
and develop the education and development offer in respect of eating disorders.  We 
have a suite of training available for specialist eating disorders teams including 
Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), Cognitive 
Behavioural Therapy for eating disorders (CBT-ed), and Whole Team Training for 
eating disorders.  We are currently launching on-line training for nursing staff and HEE 
has recently commissioned training for GPs and primary care staff.  HEE’s plans for 
2022/23 also involve enhancing and expanding this suite of training across the breadth 
of the NHS workforce. 

A38 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 HEE is commissioning training to develop the skills and knowledge of professionals 
who have contact with young people with an eating disorder; this is in direct response 
to feedback from services around their identified training needs. This includes 
additional training in Avoidant Restrictive Food Intake Disorder, training to support 
parents, carers and families, and awareness training for staff who require the skills to 
identify early signs and symptoms of an eating disorder. Work is underway to develop 
an online resources hub, covering both the physical and mental health implications of 
an eating disorder. 

I hope this response provides assurance that steps are being taken to make sure that 
there is shared learning from the death of Nichola Lomax.  We recognise the 
importance of improving the awareness of learning and resources available to clinical 
practitioners involved in caring for people with mental health conditions. We also know 
that recovery may for many people be a life-long journey and so we recognise the 
importance of making sure our staff have the right learning and skills to give the right 
support at all stages of the patient journey. 

Finally, on behalf of HEE, I thank you for bringing these matters to our attention. 

Yours faithfully, 

Executive Director of Education and Quality & National Medical Director 

A39 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 Headquarters:
Townside Primary Care Centre 
1 Knowsley Place 
Knowsley Street 
Bury 
BL9 0SN 

3 February 2022 

HM Senior Coroner 
Rochdale Coroner’s Court 
Newgate House 
Newgate 
Rochdale 
OL16 1AT 

Dear Ms Kearsley 

I write on behalf of Bury CCG in response to your Regulation 28 report received on 23 December 
2021,  issued  following  the  inquest  into  the  death  of  Nichola  Lomax. 
I  will  address  the  CCG’s 
response to each of your concerns individually below. 

1. 

Referral Criteria for the Priory and Community Eating Disorder Service 

It is acknowledged that at the time of Nichola’s involvement with the service, the community eating 
disorder service (CEDS) commissioned by the CCG and provided by Greater Manchester Mental 
Health NHS FT (GMMH) had an acceptance criteria of a BMI of 14 or more, and that this meant that 
she  was  unable  to  access  the  service.  The  service  for  Bury  patients  was  significantly  under 
commissioned in relation to the level of presenting demand and was not commissioned to provide 
medical input to support monitoring of patients with more complex needs. 

A business case to expand the service in line with national standards and Greater Manchester and 
local priorities has been agreed between the CCG and GMMH, and was formally approved by the 
CCG board on 22 December 2021.  I understand that the court was provided with a copy of this 
business case by GMMH during the course of the inquest; a further copy can be provided if needed.  
The  new  model  as  agreed  includes  the  addition  of  psychiatry/  medical  input  to  the  service  (a 
Consultant Psychiatrist and a Physical Health Practitioner) which will allow patients with a BMI of 
less than 14 to be accepted by the service and monitored medically by a clinician who has experience 
and knowledge of eating disorders.  In addition it will include: 

 
 

Increase in provision to meet the demand of 53 referrals per annum for Assessment. 
Increased psychological therapist and dietitian capacity to meet the demand for the service. 
This  will  enable  the  service  to  be  responsive  and  achieve  the  same  waiting  times  for 
treatment as for Children and Young People.  It will also allow the service to continue to offer 
high quality NICE compliant/evidence-based interventions. 

NHS Bury Clinical Commissioning Group 

Our vision is to continually improve Bury’s Health and Wellbeing by listening to you and working together across boundaries 

A40     
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   The increased capacity of psychological therapist and dietitian time will allow for the service 

to have capacity to meet the treatment length of interventions for anorexia nervosa.  

  A  range  of  NICE  compliant/evidence-based  interventions  delivered  in  both  group  and 

individual formats. This will enable service user choice.  

  Psychiatry/medical input to enable robust medical monitoring and management and support 
for staff in other setting managing individuals with the physical risks of an eating disorder. As 
part of the new psychiatry/medical pathway, the service will also be able to offer phlebotomy 
and ECGs within the service to enable ease of access and more rapid results and therefore 
a safer pathway. 

  Psychiatry  time  to  enhance  the  service  offered  to  referrals  accepted  by  the  service  with 

increased physical/mental health complexity. 

  A FREED pathway to enable a responsive service and treatments tailored to the needs to 

emerging adults with eating disorder to be delivered.  

  A SEED pathway to enable a pathway for those individuals who meet criteria for a severe 

and enduring eating disorder. 

  The service will continue to attend Care Programme Approach (CPA) of individuals referred 
to  the  intensive  parts  of  the  EDS  pathway  to  contribute  to  care  planning  and  discharge 
planning and a smooth transition back to GMMH EDS. 

  The service will continue to offer regular coproduced and cofacilitated eating disorder training 
accessibility to staff, services users and carers in all boroughs via GMMH Recovery Academy 
and other bespoke training as required.  

  The service will continue to offer carer psychoeducation, skills training, support, and a regular 

carers support group cofacilitated by staff and carers with expertise by experience. 

The inclusion of Psychiatry time will also enhance the service offer to manage referrals of increased 
complexity including those with other physical health comorbidities e.g. Type 1 diabetes and mental 
health comorbidities e.g. individuals with significant depression and those with significant personality 
disorder  traits/diagnoses,  both  of  which  have  increased  in  referrals  received  by  the  service.  The 
inclusion of psychiatry time would allow the service to support staff in other health settings including 
acute  physical  and  mental  health  hospitals  and  the  service  is  planning  to  develop  MARSIPAN 
(Management of Really Sick Patients with Anorexia Nervosa, 2014) groups across the footprint of 
the  services,  alongside  the  psychiatry  colleagues  providing  inpatient  eating  disorder  care  at  The 
Priory, Cheadle.  

GMMH have been notified of the CCG commitment to invest and are working locally with recruitment 
across Greater Manchester to the roles requires to support the expansion of the service.  GMMH 
are best placed to advise as to timescales for implementation of the business plan but the information 
we have currently is that the post for a consultant psychiatrist has been out to advert twice last year 
and there have been no applicants due to a national and local shortage.  Various methods are being 
tried to identify a suitable applicant, including considering GPSI.  I understand that work is underway 
nationally  to  look  at  training  and  a  pathway  for  non-psychiatry  staff  in  these  roles,  led  by  Health 
Education England and the Royal College of Psychiatry. 

The referral criteria for the Priory is best addressed by other organisations but we understand from 
recent  GM  meetings  that  BMI  should  not  be  used  as  a  threshold  for  determining  admission  as  a 
matter of policy and it is not now relevant in referrals to the CEDS or from there to the Priory. 

2. 

Lack of Critical Services  

The mental health provision at Fairfield General Hospital in 2020 at the time of Nichola’s attendances 
did not meet the current CORE 24 standard.  At the board meeting on 22 December 2021 the CCG 
approved  the  funding  to  commission  a  CORE  24  light  service  as  a  step  towards  meeting  the 
standards  of  a  full  CORE  24  model.  This  is  a  jointly  commissioned  service  between  Bury  and 
Heywood, Middleton and Rochdale CCG (HMR CCG).  

A business case for a full CORE 24 service was developed in conjunction with Pennine Care NHS 
Foundation Trust by a Task and Finish Group which had been set up to review the performance of 
the current service.  The CORE 24 service will: 

A41 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Provide an all age 24/7 service to the A&E and all acute wards in Bury and HMR; 
  Access to a medical staff for diagnostic assessment and treatment; 
  Provide a self-harm follow up clinic within 72 hours. 

In December 2020 the Bury Strategic Commissioning Board agreed to commissioned a pilot of an 
Urgent  Emergency  Care  by  Appointment  service  (UEC)  which  provides  urgent  appointments  for 
people with mental health needs who would have otherwise accessed urgent care services at the 
ED, contacted NHS 111 or been directed to an ED by their GP.  The service aims to provide an 
urgent mental health assessment within 24-72 hours to determine the person’s mental health needs 
thereafter.  The UEC service continues to achieve excellent outcomes in diverting activity away from 
front end A&E and provides bookable appointments for people presenting with urgent mental health 
needs. 

Given the commitments made by Bury and HMR for the UEC by appointment service PCFT have 
produced a subsequent proposal for the commissioning and provision of a Core 24 “light” service 
across Fairfield General Site and Bury and Rochdale UCC.  This request to the CCG is for a scaled 
down  version  of  a  Core  24  model  encompassing  the  all-age  element  of  a  Mental  Health  Liaison 
service however recognises the ambition to achieve Core 24 standards as per NICE guidelines over 
time  and  taking  a  phased  approach  to  investment.  Greater  Manchester  Health  &  Social  Care 
Partnership  (GMHSCP)  soon  to  become  the  GM  Integrated  Commissioning  System  (ICS)  are 
supportive of the development of the Core 24 Light service offer and have already committed FGH’s 
share of the GM transformation monies to allow PCFT to begin mobilising the service. 

The key outcomes of a Mental Health Liaison CORE 24 light service include:  

Increased medical time 

 
  Provision of an all-age service 
  Provision of all-age assessment to the acute wards 
  Provides the street triage service 
  Reduces the waiting times for patients on medical wards 
  Continuity of care for patients attending A&E or admitted to an acute ward. 

The new service will provide: 

  1 WTE liaison consultant psychiatrist 
  1 WTE medical secretary 
  1 WTE admin staff 
  2 band 6 mental health practitioners 
  Upskilling and re-banding of 3 band 5 nurses to band 6 roles 
  3 Band 2 support workers 

Recruitment for these posts has started, although limitations of workforce availability are a concern. 
There will still be some gaps remaining until the service moves to a fully compliant Mental Health 
Liaison Core 24 model in that there is no clinical lead within this model and the service would not 
meet  many  of  the  Psychiatric  Liaison  Accreditation  Network  (PLAN)  standards  which  are  best 
practice standards for liaison psychiatry services.  

Additional services are also in place to support the mental health crisis offer and mitigate the potential 
risks of the gaps remaining, including the UEC appointment service described above.  On 3rd April 
2020, Claire Murdoch (National Mental Health Director - NHS England and NHS Improvement) wrote 
to Mental Health Trust CEOs confirming that all mental health Trusts across the country, working 
alongside CCGs and ICS, to urgently take the following actions: 

  Establish 24/7 open access telephone lines for urgent NHS mental health support, advice 
and triage, and through which people of all ages can access the NHS urgent mental health 
pathway/further support if needed. 

  Ensure that the 24/7 open access crisis line telephone number(s) and contact details 
  are available to the public, clearly on the website. 

A42 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 To meet these requirements, both the GM Mental Health Trusts have developed 24/7 open access 
for known and unknown service users. This meets key criteria in the GM responding to Mental Health 
crisis model. 

Bury Peer Led Crisis service is also in place for people experiencing a mental health crisis and are 
at risk of suicide, it was launched in April 2021 as a 12-month pilot and approval is currently being 
sought to extend the term of the service based on the outcomes achieved. It is provided by a local 
organisation BIG in Mental Health and provides peer led support in a non-clinical environment to 
adults experiencing a mental health crisis including those who are at risk of suicide.  The service has 
developed robust pathways with the PCFT Mental Health Liaison service and is an integral part of 
the Bury Mental Health Crisis Pathway. 

In summary, it is acknowledged that the proposed new CORE 24 light service is still a little short of 
the full CORE 24 light, but it is a significant step towards providing a full service.  It is a pragmatic 
and deliverable step forward in response to the lack of staffing and available investment to deliver a 
full  core  24  service  now  in  one  cycle  of  investment.  A  full  CORE  24  service  will  require  further 
investment  and  workforce  development  and  we  understand  that  a  GM  business  case  has  been 
submitted to NHS England to secure the necessary funding to convert the light service into the full 
service.  In conjunction with the other initiatives described above, the mental health service offering 
is vastly improved. 

3. 

Community Monitoring of patients with an Eating Disorder 

Future plans for this are addressed in detail above; the medical monitoring of patients with an eating 
disorder will be included within the service offered by the community eating disorder service. 

It is hoped that this response provides assurance to the court that the CCG is taking the gaps in 
commissioning of mental health services identified very seriously and that action has already been 
taken  for  improvement.  Unfortunately,  wide  scale  changes  to  the  service  provision  cannot  be 
achieved immediately but it is a priority for the CCG and we are working closely with our partners to 
ensure that the actions which we have committed to are progressed as quickly as possible. 

Yours sincerely 

Accountable Officer for Bury CCG 

A43 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Greater Manchester  Health and Social Care Partnership 
4th Floor 
3 Piccadilly Place 
London  Road 
Manchester  M1 3BN 

Date: 11 February 2022 

Ms J Kearsley 
HM Senior  Coroner 
HM Coroners Court, 
Floors 2 and  3, 
Newgate House, 
Newgate, 
Rochdale, 
OL16 1AT 

Dear Ms Kearsley 

Re: Regulation  28 Report to Prevent Future Deaths – Nichola  Jane Lomax 
03/08/20 

Thank you for your Regulation  28 Report dated 17/12/21 concerning  the sad death 
of Nichola Jane Lomax on 03/08/20.  On behalf  of Greater Manchester  Health & 
Social Care Partnership  or GMHSCP (which pending  legislation  will develop  into the 
GM Integrated  Care Board (ICB) from the current shadow  structures in July 2022), I 
would like to begin  by offering our sincere condolences  to Ms Lomax’s family for their 
loss. 

Thank you for highlighting  your concerns during  Ms Lomax’s Inquest  which 
concluded  on 10th  December 2021.  On behalf  of the Partnership,  I apologise  that 
you have had to bring these matters of concern to our attention  but it is also very 
important  to ensure we make the necessary improvements to the quality  and safety 
of future services. 

The inquest  concluded that Nichola’s  death  was a result  of 1a) Liver Failure 1b) 
Anorexia Nervosa 2. Refeeding  syndrome and cholecystitis. 

A44 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
   
  
 
 
 
 
 
  
 
 
 
  
 
   
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Following  the inquest,  you raised concerns in your Regulation  28 Report to Greater 
Manchester  Health and Social Care Partnership  (GMHSCP) that there is a risk future 
deaths will occur unless  action is taken. 

I hope  the response  below demonstrates  to you and Ms Lomax’s family that 
GMHSCP have taken the concerns you have raised  seriously  and will learn  from this 
as a whole system. 

It is important to note that as part of the GMHSCP role of facilitating  GM-wide mental 
health  transformation  programmes (and  associated  investment) and providing 
strategic  support  to locality commissioners and providers on development  of 
specialist  and community mental health services - we convened all the key 
stakeholders  referenced in your report  to discuss lessons  to be learned  in a 
collaborative  way and as a system wide quality panel.  This was chaired by the 
GMHSCP Executive Medical Lead  for Mental Health  and a review panel  will be 
convened in 3 months. This will help ensure going forward a coordinated  set of 
actions in response  to this Regulation 28 Notice Report. We hope  that the 
subsequent  agency responses  that you receive positively  address all the key areas 
of concern at an individual  and  wider collective system level. 

Please  now see the Partnership’s  response  in relation  to the specific concerns you 
have raised for us,  the actions agreed  to be taken and how we can share  the 
learning  from this case. 

Referral criteria for The Priory and Community Eating Disorder Service (No. 3). 
At a meeting convened  by the GMHSCP on 28 January 2022,  it was set out that 
Greater Manchester  Mental Health NHS FT (GMMH) is working with the Northern 
Care Alliance (NCA) and the Priory to look at changing  the previous eating disorder 
pathways and resolve any  practical inconsistencies  in criteria  for admission.  GMMH 
confirmed that BMI is no longer  being  used as a criterion for admission  to their 
service at the Priory. Access will be based  on specialist  clinical assessment  of the 
person’s  level of need, and so will give full attention  to physical and mental  health 
red flag signs and  aligned  to the national  MARSIPAN framework. 

While  currently each locality CCG holds  an individual  contract with GMMH for the 
Adult Eating  Disorder  (AED) service they currently commission, in July 2022,  these 
contracts will novate to the GM ICB and  over the remainder  of the 2022/23  financial 
year, will be brought  into  a single  contract with each provider delivering specialist 
eating  disorder  services.  This will enable a positive  opportunity  to resolve  any further 
unwarranted  variation in referral criteria and commissioned care pathways across 
GM. 

In advance of this,  GMHSCP MH Programme Team are working with partners to 
ensure  the Children  and Young  Person’s  Eating  Disorders working group  that is 
already in place is broadened  to become an all-age  group.  This will address wider 
transition  issues  between  Children’s  and  Adult Eating  Disorder  services - an area of 
particular  concern for this patient  group. Actions to ensure connectivity of evidence-
based  pathways that apply  consistent  referral criteria will be a key part of the work of 
this group. It will involve clinicians,  commissioners,  service providers and service 
users.  This is something  that has already  been encouraged  over the past  year in the 

A45 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 development  and expansion  of the  GMMH Adult Eating Disorders  service, as further 
locality and GMHSCP investments have been  agreed. 

All this work will ensure  dedicated  space  and attention  in Greater Manchester  to 
work through the issues  highlighted  in the Regulation  28 Report and share learning 
between  all stakeholders.  This will also  include formal oversight  and assurance 
through  to the refreshed Quality Board function within GMHSCP and the GM ICB 
from July 2022. 

Lack of critical services  (No. 4). 
GMHSCP acknowledges that the mental health  provision at Fairfield General 
Hospital  (FGH) in 2020  at the time Nichola was attending  did not meet the national 
Acute Hospital  Liaison  Mental Health Core 24 standard.  However, since this time the 
investment  is now in place as agreed with both Bury and  Heywood, Middleton,  and 
Rochdale  CCGs and GMHSCP. This will provide  a Liaison  Mental Health  Core 24-
Lite service at Fairfield Hospital.  This is a firm step towards core 24 compliance and 
will enable  an all-age  offer, with increased  joint working between  alcohol,  adult 
mental health  and older  people’s  services. As a result,  Pennine Care Foundation 
Trust (PCFT) working with the Northern  Care Alliance have now initiated  the work to 
recruit to and mobilise  this service. However, the ambition  is to move to a fully 
compliant Liaison  Mental Health  core 24 service offer at FGH. 

GMHSCP have submitted a formal proposal  to NHS England  to release  just over £1 
million  (as the fair share allocation  of national service transformation  funding) to 
support  strengthening  the GM MH Crisis and Liaison  services. This will provide 
additional  investment  to enable  a Core 24 service offer at FGH and 
Tameside/Wrightington,  Wigan and Leigh  Hospitals.  This will mean that further 
medical cover, clinical leadership  will be in place, with further capacity to reach the 
PLAN accreditation  standards.  This work will support  100%  GM-wide Core 24 cover 
across all  the Acute Hospitals  in the coming 2 year. This will exceed the national 
ambition  through the NHS Long Term Plan  for 70%  cover across GM. 

GMHSCP also  acknowledges that the commissioned  adult  eating  disorders  service 
in Bury (like many areas of the country) was insufficient to meet local need.  Since 
then,  funding has now also been confirmed between Bury CCG and GMHSCP to 
implement the GMMH Adult Eating  Disorders Business  Case. 

This will ensure across Greater Manchester commissioners  and providers meet the 
NHS Long Term Plan goals for comprehensive  community adult  eating  disorder 
services delivering  enhanced service offers in line with current best  practice clinical 
guidelines,  including: 
•  The service accepting individuals  with differing severities of eating  disorders  and 
offering a stepped  care model in line  with National  Collaborative  Centre for MH 
Guidelines  (2019). 

•  Timely, effective, evidence-based  treatments,  care and  support  that meet the 

needs  of individuals  with the full range  and severity of eating disorders 
•  NICE compliant/evidence-based  psychological  therapy will be offered in 

individual  and group formats 

•  Early intervention  pathway (First Episode  & Rapid Early Intervention  for Eating 
Disorders or FREED) as an evidence-based,  specialist  service model  for 16- to 

A46 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 25-year-olds  with an eating  disorder  of less than 3 years’ duration  – with a central 
focus on reducing the duration  of an untreated eating  disorder  through  rapid 
access to assessment  and treatment optimising  clinical outcomes 

•  Specific pathway for severe  and enduring  presentations  with a focus on 

improving quality  of life and reducing  hospital  admissions  for individuals  who 
meet a severe and enduring  eating  disorder  (SEED) diagnosis 

•  Medical monitoring and management  and support  to staff working in medical 

settings. 

•  Specialist  dietetic  assessment  and intervention 
•  Family therapy  to ensure  transitions  from CYP Eating  Disorder Services are 

optimal. 

•  Support  and empower families, partners,  carers and the person’s  support 

network 

•  Offer advice, support  and  consultation  to other  services involved in a person’s 

care 

•  Coordinated  care and work with other services to reduce and  prevent gaps in 

care during service transitions 

•  Clear processes  around managing  risk and safety as well as unattended 

appointments. 

•  Appropriate  clinical supervision  to ensure  professionals  remain competent to 

• 

deliver evidence-based  treatment 
Improved awareness of the service in the community, the  importance of early 
identification  and reduce the stigma to increase  help-seeking  in the local 
population 

•  Collaboratively  use routine outcome measurement  to support  a person  to identify 

and meet their goals  for recovery 

•  Actively seek out feedback from the people  and their  families who are 

experiencing  the service 

In additio