Megan Davison

From 
Parliamentary Under-Secretary of State  

39 Victoria Street  
London  
SW1H 0EU  

26 September 2024  

Our Ref: 

Ms Alison McCormick  
Assistant Coroner  
HM Coroner’s Service  
The Old Courthouse  
St Albans Road East  
Hatfield  
AL10 0ES  

By email: 

Dear Ms McCormick,  

Thank you for the Regulation 28 report of 15 July 2024 sent to the Department of Health 
and Social Care about the death of Megan Leanne Davison.  I am replying as the Minister 
for Patient Safety, Women’s Health, and Mental Health.   

Firstly, I would like to say how saddened I was to read of the circumstances of Megan’s death 
and I offer my sincere condolences to her family and loved ones. The circumstances your 
report describes are very concerning and I am grateful to you for bringing these matters to 
my  attention.  Thank  you  for  the  additional  time  provided  to  the  department  to  provide  a 
response to the concerns raised in the report.  

You have raised concerns about the treatment pathway for Type 1 Diabetes with Disordered 
Eating (T1DE) and Diabetic Ketoacidosis (DKA), the lack of a local integrated healthcare 
system for patients with diabetes and disordered eating and the development of shared 
clinical records across NHS and private providers.  

In preparing this response, departmental officials have made enquiries with NHS England 
and Hertfordshire and West Essex Integrated Care Board.   

  
  
  
  
  
 
 
 
 
 
  
  
 I would like to assure you that since Megan’s death, NHS England has provided funding for 
eight Integrated Care Boards (ICBs) across the country to support the development and 
establishment of T1DE services in every NHS region.  Patients in Hertfordshire and West 
Essex are able to access these pilot services.   

To support greater understanding, NHS England invested £4.5m in pilots to test, trial and 
evaluate the effects of integrated diabetes and mental health pathways for the identification, 
assessment and treatment of people with Type 1 diabetes and disordered eating.  

Central to the service model delivered in the eight pilot sites, which are distributed in each 
region of the country, is delivery of a model treatment and care pathway that integrates 
various healthcare disciplines, including diabetes and mental health to address the complex 
nature of T1DE. Funding has been provided on a pump prime basis and the responsibility 
for the longer-term sustainable provision of care for these patients sits with Hertfordshire 
and West Essex Integrated Care Board.   

A nationally commissioned evaluation has shown the positive impact that the provision of 
T1DE services can have for patients, including reductions in HbA1c, which is linked to 
reduced rates of diabetes complications, and reduced rates of emergency admissions.   

It is expected that ICB leads should consider these evaluation findings in making decisions 
about the future provision of T1DE services.   

NHS England is drawing on learning from existing T1DE services, other emerging evidence 
and the findings of the recent ‘Type 1 diabetes and disordered eating’ parliamentary inquiry 
on the 23 January 2024, to ensure all areas of the country are supported to improve care for 
those identified as having T1DE. The emergence of these future plans are subject to future 
spending review settlements for the NHS and level of funding from the NHS England budget 
allocated to T1DE.  

Evaluation by the NHS of the initial Type 1 Diabetes with Disordered Eating service (T1DE) 
pilot sites (in London and Wessex) demonstrated a mean reduction in HbA1c of between 
2.3% to 2.5%. Assuming that this level of reduction is maintained, the lifetime QALY gain of 
these services was estimated at 1.49, which would be cost effective up to a net lifetime cost 
of £29,800-£44,800.   

In response to these initial evaluation findings, NHS England expanded the T1DE 
programme, supporting provision of new services in an additional five sites from September 
2022, expanding coverage to more areas of the country. It is expected that these services 
will generate further evaluation data to consolidate these early findings, which can be used 
to inform national and local policy decisions.   

NHS England is also working closely with the first wave of pilot sites including London to 
ensure that the newer services can benefit from their learning and experience when 
considering local funding options in advance of March 2025, when the national funding for 
the five new sites will come to an end.  

  
 NHS England is assisting ICBs to develop local funding arrangements through the provision 
of evaluation data, a national programme of support workshops, and an online platform to 
share learning and good practice.  

With regard to the lack of a local integrated healthcare system for patients with diabetes and 
disordered eating in East and North Hertfordshire, it is essential that mental health services 
meet patients' physical as well as their mental healthcare needs either through their own 
appropriately qualified and experienced staff or in partnership with other providers. This 
requires mental health workers to be provided with adequate training and guidance on 
monitoring physical health, and importantly how to escalate and respond to concerns as 
needed.   

The ICB commissions diabetes services and in East and North Hertfordshire and there is 
collaborative working between community and acute diabetic teams, with a history of 
shared clinical posts. In General Practice, the ICB has invested in improvements in diabetic 
care as well as enhanced physical health checks for people with mental health conditions. 
Investment has also been made into Talking Therapies for people with long term physical 
health conditions, including diabetes. The ICB has worked with local mental health 
providers to improve access and care for people with an eating disorder or disordered 
eating, with associated additional community service transformation funding.  

Thank you for also highlighting your important concerns about the pressures on NHS 
mental health services, the interface between private practitioners and NHS providers and 
the sharing of medical information between the two.  I note that your report has also been 
sent to the Hertfordshire and West Essex Integrated Care Board as this is a local matter 
and I would expect that the ICB will want to ensure the appropriate steps are taken in 
response.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

                                                          All good wishes

Charter House 
Parkway 
Welwyn Garden City 
Hertfordshire 
AL8 6JL 

23 August 2024 

Re: Regulation 28 Report to Prevent Future Deaths- Megan Davison who died on 4th August 
2017 

Dear Ms McCormick 

Thank you for your Report to Prevent Future Deaths dated 15th July 2024 concerning the death of 
Megan Leanne Davison on 4th August 2017. In advance of responding to the specific concerns 
raised in your report, I would like to express my deep condolences to Megan’s family. 
Hertfordshire and West Essex Integrated Care Board (ICB) are keen to assure the family and the 
Coroner that the concerns raised about Megan’s care have been listened to and reflected upon. 

Within your report you have detailed three specific matters of concern, I have addressed each in 
turn below; 

1.  On a national level there is not a system which is capable of being operated in a way 
which will ensure proper integrated healthcare for patients with Type 1 Diabetes with 
Disordered Eating (T1DE). Specifically, there is no formal diagnosis for T1DE, no 
treatment pathway for T1DE and no complete treatment pathway for Diabetic 
Ketoacidosis. 

We note that your report has also been sent to the Secretary of State for Health due to the 
national matter of concern identified. I will therefore not respond further on this specific issue. 

2.  At a local level in East and North Hertfordshire there is no integrated healthcare system 
for patients with diabetes and eating disorder as there is in the west of the county. 

The ICB recognises the complex needs of patients such as Megan who have both type 1 diabetes 
and disordered eating (T1DE), and that these needs are best identified and managed through 
coordinated care and case management. The development of national advice on diagnosis and 

, Chief Executive 

, Chair 

 
 
 
 
 
             
 
 
 
 
 
 
 
 management of T1DE (as per the above item) would help to strengthen improvement locally and 
more widely.  

The ICB commissions diabetes services and in East and North Hertfordshire and there is 
collaborative working between community and acute diabetic teams, with a history of shared 
clinical posts. In General Practice, the ICB has invested in improvements in diabetic care as well 
as enhanced physical health checks for people with mental health conditions. Investment has also 
been made into Talking Therapies for people with long term physical health conditions, including 
diabetes. The ICB has worked with local mental health providers to improve access and care for 
people with an eating disorder or disordered eating, with associated additional community service 
transformation funding.  

The ICB is working closely with NHS England’s regional mental health and transformation team, to 
learn from recent national pilots to trial pathways for T1DE patients and apply this within the 
Integrated Care System (ICS). The regional team have confirmed they are happy to work with the 
ICB to ensure any learning from the pilots, as well as relevant national guidance, can be 
incorporated into our local model. Locally, Mental Health commissioners lead an implementation 
group with membership from all ICB partners including primary care, community commissioning, 
regional teams, the voluntary sector, service users, and carers to support quality improvement and 
delivery of eating disorder services and physical health checks. This work will inform further 
pathway development and improve access to physical health services for people with serious 
mental health conditions. 

Across the ICS, complex patients requiring case management are now proactively identified and 
managed through local Integrated Neighbourhood Teams. These bring together professionals 
from across relevant services to understand the holistic needs of individuals and develop joint 
plans.  

Where necessary, the ICB (via its clinical teams) can help to organise case-based discussions.  
We are reinforcing the availability of this support and ensuring there is a clearer process for local 
providers to escalate cases to the ICB. If a patient is identified as needing joint input from diabetes 
and mental health services, the ICB can convene a case conference as appropriate, with the 
relevant teams to develop an agreed management plan. Details on how local providers can 
access this process will be in place by November 2024, enabling clinicians to make best use of 
this support. 

To address variation in service provision within different parts of the ICS, the ICB is working with 
local providers to develop a new, integrated model of diabetic care reflecting the needs of all 
diabetic patients. This includes the management of complex cases involving multi-disciplinary 
case management, including mental health support.  

3.  Whilst there have been significant advances in developing shared clinical records 

systems across primary and secondary care since Ms Davison's death in 2017, none of 
the shared records systems extends to organisations which are deemed to be private 

, Chief Executive 

, Chair 

 
 
 
 
             
 
 providers, such as The Priory. You have heard evidence from the Chief Medical Officer 
of The Priory that record sharing which includes private providers would help to 
prevent future deaths. 

When considering shared clinical records there are two areas that we need to review; the 
technological aspect and then the data sharing arrangements that are in place.  

The model for all shared care records is that when an appropriate clinician or carer opens the 
patients record on their local electronic patient record, they then click on a shared care record, 
and it will display any data held for that patient.  

Within Hertfordshire and West Essex Integrated Care System our ambition is to give access to 
any appropriate person providing care. However, a phased approach to implementation is 
required to manage this safely as well as due to the significant costs involved. To provide access 
to the shared care record requires a connection to each care providers system which involves 
technical integration, information governance process and ongoing revenue funding for that 
connection.  

Within the current phase of work, the ICB now has a shared care record with a rich volume of data 
being shared from a number of organisations connected; this does include some private providers 
such as local hospices. 

Our future plan is to be able to extend the roll out to as many providers as possible including 
private providers and we do recognise the benefit this will bring in relation to patient safety. We 
are mindful that national funding for this work was reduced in 2023/24 and we are awaiting 
clarification regarding future funding for 2024/25 and beyond; this has meant that we have not yet 
been able to roll out further at this stage. Hertfordshire and West Essex ICB has made our views 
known on this point and we hope to progress with further implementation should further national 
funding be identified.  

In relation to data sharing agreements, the East of England Region uses “MyCareRecord” which 
enables health and care professionals to securely access patient information, across different 
organisations that are part of the MyCareRecord agreement. Currently Hertfordshire and West 
Essex ICB host MyCareRecord on behalf of the whole region.  

In a similar way to the shared care records described above, there are funding challenges that we 
are currently looking to resolve regionally. In order to extend this to more care providers, 
additional funding is needed to both connect up new providers and to safely and securely maintain 
the technology.   

In the meantime, we continue to work with local providers to ensure that patient information 
relating to their care is shared appropriately on a case-by-case basis. 

Additionally, the report to prevent future deaths will be shared with the local System Quality 
Group, and discussed, to ensure wider learning from Megan’s death and the valid matters of 
concern that you have identified.  

, Chief Executive 

, Chair 

 
 
 
 
             
 
 Thank you for bringing these important patient safety issues to my attention. I do hope my 
response provides some assurance to you and Megan’s family regarding the actions being taken 
in relation to the care provided to patients within east and north Hertfordshire with type 1 diabetes 
and disordered eating.  

Please do not hesitate to contact me should you require any further information or clarification. 

Yours sincerely, 

Chief Executive Officer 

Dr Jane Halpin, Chief Executive 

             Rt. Hon. Paul Burstow, Chair