Prevention of Future Deaths reports · 2025

REDACTED

Regulation 28 report to prevent future deaths, reference 2025-0314, written 23 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report23 Jun 2025
Reference2025-0314
DeceasedREDACTED
CoronerAndrew Hetherington
Coroner areaNorthumberland
CategoryChild Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths
Organisation namedNorthumbria Healthcare NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published5

The report

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

ANDREW HETHERINGTON
H M Senior Coroner for Northumberland

County Hall, Morpeth, Northumberland NE61 2EF
Tel 01670 622600
Email coroners@northumberland.gov.uk

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Northumbria Healthcare NHS Foundation Trust
2. 49 Marine Avenue Surgery
3. Moorbridge School
4. North East and North Cumbria Integrated Care Board
5. Department of Health

1

2

CORONER

I am Andrew Hetherington, Senior Coroner for Northumberland.

CORONER’S LEGAL POWERS

I make this report under paragraph 7, schedule 5, of the Coroners and Justice Act
2009  and  Regulations  28  and  29  of  the  Coroners  (Investigations)  Regulations
2013.
http://legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made

3

INVESTIGATION and INQUEST

I commenced an investigation into the death of REDACTED Deceased. The

investigation concluded at the end of the inquest on 19 June 2025.

The  medical  cause  of  death  was  confirmed  as  1a  Pulmonary  aspiration  of

stomach contents 1b Gastroparesis 1c Extreme Malnutrition

The conclusion of the inquest was a narrative conclusion: Died as a result of the

effects of extreme malnourishment. Opportunities to recognise the weight loss

 and escalate care were missed after November 2023. It is not possible to say

whether the outcome could have been prevented with earlier escalation.

4

CIRCUMSTANCES OF THE DEATH

The deceased was aged 17 years of age. She had a diagnosis of Autistic

Spectrum Disorder and suffered with anxiety. She complained of symptoms of

brain fog, syncope, blurred vision and chronic fatigue which she attributed to

COVID 19 or a physical cause.

She experienced significant weight loss.

She underwent a number of investigations including for an autonomic

dysfunction (Postural Orthostatic Tachycardia syndrome) and no formal

diagnosis was made. The investigations raised the suspicion of vasovagal

response and deconditioning. She admitted to restricting her diet to manage her

symptoms.

The deceased was seen in the syncope clinic on 20 November 2023. Her weight

was recorded as 42.9 kg with a BMI of 16.6. The Consultant Physician was

concerned that the deceased was underweight and further investigation of her

weight loss was appropriate. On 20 November 2023 referrals were sent to the

General Practitioners, Child and Adolescent Mental Health Services and

Dietetics to monitor her weight. By the time of her admission to hospital on 30

April 2024 her weight was 26.6 kg. I heard this was 50% of what would be

expected as her median weight. From 20 November 2023 her weight had

decreased by 16.3 kg.

She was admitted to Northumbria Specialist Emergency Care Hospital from

home on 30 April 2024 in an advanced state of starvation and with a very low

Body Mass Index. The clinicians recognised the imminent risk to life. She

agreed to nasogastric feeding and a nasogastric tube was placed on 2 May

2024. On 3 May 2024 she was placed under Section 2 of the Mental Health Act

for assessment and treatment.

On 5 May 2024 before insertion of a central venous line into the jugular she was

placed head down, felt nauseous and went on to vomit. She was rolled over

onto her left side and oropharyngeal suction was applied. There was a rapid

 decline in her condition, she became bradycardic and cardiac output was lost.

Despite cardiopulmonary resuscitation she died within the critical care unit at

Northumbria Specialist Emergency Care Hospital at 10.25 hours on 5 May 2024.

5

CORONER’S CONCERNS

To Marine Avenue Surgery and Northumbria Healthcare NHS
Foundation Trust

1.The deceased’s weight was not adequately monitored from November
2023.

I am concerned there was no physical or face to face monitoring of the

deceased’s weight from November 2023. I heard about the importance of

physical eye to eye contact and examination on a face-to-face basis so that one

can see evidence of the skin, properly see the patient’s face and when doing the

height and weight asking for the removal some of their clothing to assess

muscle mass.

2.There was no referral to gastroenterology

I am concerned there is confusion as to the guidance on Consultant-to-

Consultant referrals.

The Consultant Physician wrote to the GP saying, "please monitor weight loss

and refer into gastroenterology services for further assessment".

The GP was aware of guidance regarding Consultant-to-Consultant Referrals

that had been updated in October 2023 so that Consultants could and should be

directly referring patients themselves to another speciality if there was a clinical

reason to do so, rather than passing that task back to the GP. The Consultant

Physician told me the guidance was not cascaded down to trust level until

December 2023 after the Consultant Physician saw the deceased and that the

final guidance has not yet been received.

To Northumbria Healthcare NHS Foundation Trust

3.The deceased was discharged from CAMHS in December 2023 without
being seen in person, spoken to or weighed

The second referral to CAMHs was following the Consultant Physician’s letter

dated 20 November 2023. The request was “I would be grateful if you could see

 this young girl urgently for advice with regards to oral intake. She has lost weight

over a number of months and clinical history as outlined above”. The deceased

was offered an appointment in keeping with the 4-week national waiting

timescale for CYP with an eating disorder.

Contact was made with mum on 24 November and an appointment offered for

13 December 2023. During the call Mum told staff the deceased “hated CAHMS

so might kick off and refuse to come”. Mum cancelled the appointment on 11

December 2023.

CAMHs contacted mum by telephone on 12 December 2023. Mum said that the

deceased was not aware that she had been referred to CAMHs, was not willing

to attend. Again, there was no exploration as to why that was the case and no

direct contact with the deceased.

(a) I am concerned the deceased was discharged from CAMHs on 12 December

2023 without being seen face to face or spoken to directly.

(b) I am concerned there was no scrutiny as to why the deceased was reluctant

to engage and not attend appointments.

4.There was no in person assessment by dietetics or escalation of care

The deceased was assessed via telephone on all occasions. I am concerned

that whilst telephone assessments expedited contact there was no in person

face to face assessment to record weight or to take and record clinical

observations.

At assessment on 2 January 2024, the deceased was not aware of her current

weight. A weight history from the 20 November 2023 and a 2022 weight were

noted. Her BMI was calculated as 17.

On 5 March 2024 the deceased was reviewed by a specialist dietitian again by

telephone. The deceased self-reported her weight to be 33kg with a calculated

BMI of 13.4.

The Medical Emergencies in Eating Disorders (MEED) guidelines are used to

identify at the earliest stage possible the appropriate care and treatment to be

provided. It identifies BMI calculators in the green, amber and red.

 Red or high risk would be a BMI less than 13.

The next specialist dietitian review took place on 26 April 2024, 2 weeks later

than planned again by telephone. The self-reported weight was 31.8kg with a

calculated BMI of 12.9

I am concerned that there was no escalation of care or onward referral, and I am

concerned about staff’s understanding of the Medical Emergencies in Eating

Disorders (MEED) guidelines.

To Marine Avenue Surgery, Northumbria Healthcare NHS

Foundation Trust and Moorbridge School.

5.The Passage of information/communication

Communication: I heard about the importance of the passage of information.

During the course of the inquest a witness was taken to the SEN chronology

and an entry dated 1 March 2024 which refers to a conversation with the

deceased’s mother on 29 February 2024 where she described the deceased

having significant problems with her eating habits, losing weight and refusing to

eat foods that would be good for her and put weight on her.

I am concerned that this information was not shared to an appropriate body.

To North East and North Cumbria Integrated Care Board and
Department of Health

6.One records system - weights, heights and Body Mass Index (BMI)

I heard that patient care records are held on different care record systems within

the NHS which are not universally accessible to healthcare organisations,

healthcare professionals or patients. I heard good examples of accessible

records such as the Great North Care Record (GNCR) and Systm0ne operated

by some in Primary Care.

I am concerned there is not one accessible system for weights, heights and

BMI.

 To North East and North Cumbria Integrated Care Board and
Department of Health

6.Oversight of care in an Outpatient setting

There is a lack of clarity regarding oversight of care in an outpatient setting.

The Patient Safety Incident Investigation report identified that there was a lack

of oversight of care. The early help assessment team were stepped down in

2022 and they may have been the appropriate team to maintain oversight of

care. The SI report comments that the referrals between services were all

appropriate but it was unclear who had oversight of all the care and that the

investigation team felt that oversight was unclear and that arrangements around

risk assessment escalation safeguarding and GP involvement could have been

better through improved communication.

I heard that in an inpatient setting there are key NHS standards set around what

was described as “the name at the end of the bed” which healthcare

professionals work within.

I am concerned that in an outpatient setting there is no specific guidance

regarding oversight of care within the NHS. No one department or clinician has

overall responsibility or accountability.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you

have the power to take such action.

7

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this

report, namely by 18 August 2025.

I,  the  coroner,  may  extend  the  period.  Your  response  must  contain  details  of

action  taken  or  proposed  to  be  taken,  setting  out  the  timetable  for  action.

Otherwise you must explain why no action is proposed.

8

COPIES and PUBLICATION

I have sent a copy of my report to the following Interested Persons

   The family of deceased.

  Northumbria Healthcare NHS Foundation Trust

  The 49 Marine Avenue Surgery

  Moorbridge School

  North East and North Cumbria Integrated Care Board

  Department of Health

I am also under a duty to send the Chief Coroner a copy of your response. The

Chief Coroner may publish either or both in a complete or redacted or summary

form. He may send a copy of this report to any person who he believes may find

it useful or of interest. You may make representations to me, the coroner, at the

time of your response, about the release or the publication of your response by

the Chief Coroner.

9

Date: 23 June 2025                 Signed:

Andrew Hetherington HM Senior Coroner for Northumberland

Responses

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

Response from 49 Marine Avenue Surgery (PDF)
NPC
49 Marine
Avenue

NHS
Providing NHS services

Response to Regulation 28 Report into the death of 

From: 49 Marine Avenue GP Surgery (NPC Surgery)
Date: 13th August 2025
To: H.M Senior Coroner, Mr Andrew Hetherington, Northumberland Coroners Office
Response Due: 18th August 2025

Dear Sir,

We  acknowledge  receipt  of  the  Regulation  28  report  concerning  the  tragic  death  of
 and extend our sincere condolences to her family. We take this matter
very  seriously  and  appreciate  the  opportunity  to  reflect  on  the  concerns raised  and  to
outline our learning and planned actions to improve care delivery.

Summary of GP Surgery Involvement:

1.  Monitoring of Weight and Physical Health: We recognise that from November
2023 there was inadequate face-to-face monitoring of 
 weight. As a GP
surgery,  we  rely  on  multidisciplinary  collaboration  and  clear  communication  to
monitor  complex  cases.  We  invited 
  for  a  face-to-face  consultation,
including weighing, by  phoning and then texting directly to  her  mother; however,
/her  family  did  not  contact  us  to  attend  for  a  weight  appointment.  We

regret that despite these efforts we were unable to engage her directly.

2.  Referral  to  Gastroenterology:  We  acknowledge  the  confusion  around  referral
pathways between consultant services and use of the term "consider referral" and
that  the  requested referral did  not  occur. We  recognise this  represents a  critical
missed  opportunity  to  escalate  care.  Going  forward,  we  will  ensure  clearer
understanding of referral pathways and strengthen communication with secondary
care colleagues to prevent similar delays.

3.  Communication  and  Information  Sharing:  The  report  highlights  concerns
regarding the  flow  of  information from  other  agencies, including the  school  and
mental health services. We concur that a more robust system for sharing relevant
clinical and safeguarding information is essential. We are committed to improving
multidisciplinary communication, including liaising more proactively with  schools,
mental health services, and social care teams involved with patients at risk.

Learning and Actions to be Taken:

Part of  Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127)  Enhanced Face-to-Face Contact: The GP surgery already runs a primarily face-
to-face appointment system, but we have reminded the team of the importance of
this means of access, particularly where weight loss or malnutrition is a concern,
to  ensure  accurate  physical  assessments.  We  will  continue  to  reiterate  the
importance  of  face  to  face  contacts  at  our  monthly  meetings  and  when  any
changes to appointment ledgers are considered.

(cid:127)  Clarification of Referral Pathways: We  are fully committed in working with our
secondary care colleagues to ensure that any information that is shared between
primary and secondary healthcare pathways and communication is implemented
as part of the learning and actions from this case. This will be discussed, for action,
at  the  North  East  and  North  Cumbria  GP  Provider  interface  group  by  October
2025.  If new pathways are introduced, we will seek to confirm they are operational
rather  than assume everyone is  aware.  If  there  is  any  uncertainty  or  ambiguity
regarding the request in a letter, we will write back to the Consultant to clarify.  If
any  actions  are  unable  to  be  carried  out  for  any  reason,  we  will  write  to  the
Consultant to inform them and ask if any further action on our part is needed.  We
are  reviewing  internal  processes  to  clarify  responsibilities  and  improve  timely
referrals for specialist input.

(cid:127) 

Improved Multidisciplinary Communication: We  are  developing strategies for
better  information  sharing  among  primary  care,  secondary  care,  schools,  and
mental  health  services  and  have  met  with  Northumbria  Healthcare  Foundation
Trust  regarding  this.  Specifically,  we  are  looking  into  setting  up  monthly
Multidisciplinary  Team  Meetings  (MDTs),  to  enable  sharing  of  information  and
timely interventions.

(cid:127)  New  Processes  and  Policies:  We  have  developed  an  Eating  Disorders
Management  Standard Operating  Procedure (SOP)  and  a  Safe  Management  of
Under-18s with Eating Disorders Policy. These cover the management of patients
presenting  with  weight  loss  (attached).  An  initial  audit  has  been  undertaken  to
review  all under-18s  who  have  an  eating  disorder at  49  Marine Avenue Surgery
and ensured our management is compliant with the new SOP and policy and that
we have a robust review and recall system in place.

(cid:127)  Training  and  Awareness:  We  will  provide  staff  training  on  the  Medical
Emergencies  in  Eating  Disorders  (MEED)  guidelines  to  increase  awareness  of
clinical red flags and escalation pathways.

Part of Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127)  Patient Engagement: We acknowledge the challenges in engaging adolescents
reluctant to attend appointments. We will review our approach to invite and follow-
ups, considering additional support methods, including involvement of family and
community  services,  to  improve  attendance  and  monitoring.  We  have  recently
reviewed our  Safeguarding Policy  (March 2025)  which  includes an  Appendix on
"Child Not Brought".  This includes several safeguards to check a child is brought
to an appointment/monitoring and checklists to re-engage and flag concerns if this
is ongoing.  The policy has been shared with the team.

Part of  Northumbria PRIMARY CARE

  NPC
49 Marine
Avenue

NHS
Providing NHS services

49 Marine Ave Surgery, as part of

Northumbria Primary Care (NPC)

SOP: Management of Patients Under 18 with Eating Disorders

Author: 

 (Medical Director NPC)

Date: 01/08/2025

1. Scope and Purpose

This SOP applies to all general practice staff providing initial assessment and ongoing
care for patients under 18 presenting with suspected or diagnosed eating disorders
(anorexia nervosa, bulimia nervosa, binge eating disorder, OSFED).

2. Overarching Principles

(cid:127)  Management is multidisciplinary and family-inclusive, with early referral to

specialist community-based eating disorder teams when indicated.

(cid:127)  Safeguarding, capacity/consent, and physical health monitoring are core, non-

delegable responsibilities.

3. Recognition, Screening, and Initial Assessment

(cid:127)  Be alert to eating disorders in young people with low BMI, unexplained weight

loss, growth faltering, amenorrhea, repeated vomiting, Gl symptoms,
psychosocial distress around food/weight, or mental health concerns.

(cid:127)  Ask screening questions directly: e.g., “Do you think you have an eating

problem?” and “Do you worry excessively about your weight?”

(cid:127) 

If a gastrointestinal cause for the weight loss is suspected, early referral to
secondary care, gastrointestinal services should be considered at the outset or
at any other time in the management of the patient if their condition changes and
suggests a gastrointestinal problem.

Part of  Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

Initial assessment must include:

(cid:127)  Physical health: weight, height, BMI centile, pulse, BP (lying/standing),

temperature, signs of dehydration or medical instability (refer to MEED: Medical
Emergencies in Eating Disorders guidance).

(cid:127)  Mental health: risk of self-harm or suicidality, psychological distress, depression,

anxiety.

(cid:127)  Social/family context: eating patterns, exercise, impact on education/social

function.

(cid:127)  Safeguarding: assess risk of abuse/neglect in every case, document and

escalate concerns per local protocol.

4. Immediate Risk Assessment

(cid:127) 

Immediate hospital admission is required for any child or young person with
features of acute physical risk (marked bradycardia, hypotension, hypothermia,
syncope, electrolyte disturbance, severely low BMI centile for age, rapid weight
loss, or evidence of systemic compromise).

(cid:127)  Severely low BMI in children/adolescents is typically: BMI for age below
the O.4th centile (or less than the 5th centile if no contextual factors are
given), or BMI below 70-75% of the median for age/sex and must be
interpreted in conjunction with clinical factors and physical health status

(cid:127)  Refer urgently to specialist eating disorder services if eating disorder is

suspected and there is significant impairment or risk.

5. Safeguarding, Consent, and Confidentiality

(cid:127) 

Involve children/young people and their families in all decisions, unless harmful
or not in best interests.

Part of  Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127)  Assess and document Gillick competence (under 16): seek valid consent or
parental involvement as appropriate. For 16-1 7s, assume capacity unless
evidence to the contrary.

(cid:127)  Respect confidentiality but explain exceptions (risk to self/others). Record legal

authority for decisions, especially in contested or overridden treatment.

6. Ongoing Care and Referral

(cid:127)  Every patient should have a care plan for ongoing physical and psychological

monitoring, coordination with specialist services, and emergency action.
(cid:127)  Growth and physical health (weight, height, vital signs) should be monitored

frequently per specialist or local protocol—seek paediatrician input for faltering
growth or medical instability.

(cid:127)  Psychological/medical comorbidities (e.g., diabetes, depression): coordinate

MDT management and review regularly.

(cid:127)  People referred to specialist services should begin assessment and treatment
within 4 weeks (for children and young people), in line with NHS Access and
Waiting Time Standards.

7. Family and Psychoeducation

(cid:127)  Family interventions are first-line: offer evidence-based family therapy (such as

anorexia-focused family-based therapy, 32  40 sessions over 12-18 months with
additional sessions for parents/carers).

(cid:127)  Provide or refer for psychoeducation to patient and family about risks, nutrition,
relapse prevention, impacts on mood, social function, body image, and safety.

8. Referral Pathways and Escalation

(cid:127)  Refer all suspected cases to local community-based eating disorder teams

(children/young people) without delay. Follow the NHS England Access and
Waiting Time Standard targets.

(cid:127) 

In urgent risk, refer to paediatric inpatient care with facilities for specialist
refeeding and monitoring—use age-appropriate settings.

Part of Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127) 

If treatment is refused but deemed essential, follow legal pathways (Mental
Health Act, Children Act; seek senior and legal advice).

9. Medicines Management

(cid:127)  Medication is never sole therapy for eating disorders in under-18s; it may be

used as adjunctive treatment only under specialist guidance.

(cid:127)  Review all current prescriptions for potential health risks (QT prolongation, risk of

dehydration, etc).

10. Documentation

(cid:127)  Record all assessments (including physical and psychological risk), consent

discussions, safeguarding steps, referrals, and communications
contemporaneously using appropriate coding (e.g., “vulnerable child”, “child
protection”).

11. Audit and Quality Assurance

(cid:127)  Review all cases regularly at practice MDT meetings and audit care against

NICE NG69 and MEED standards.

(cid:127)  Seek regular updates and training for all staff in safeguarding and eating disorder

recognition/management.

Key References

NICE NG69: Eating Disorders—Recognition and Treatment

MEED (Medical Emergencies in Eating Disorders) guidance

Part of  Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

Policy for the Safe Management of Under 18s with Eating Disorders

August 2025

Operational Summary

This policy provides a comprehensive, standardised framework for the identification,
assessment, referral, and ongoing management of patients under 18 presenting with
eating disorders. It includes the use of SystmOne with embedded Ardens Templates,
specifies safeguarding responsibilities, and sets out coordinated working with local
partners including CNTW, CYPS, Northumberland Foundation Trust, and Newcastle
Foundation Trust, in line with current legal and clinical guidance.

1. Introduction

Eating disorders in children and young people are serious mental health conditions
associated with significant physical and psychological morbidity. General practice
teams have a vital role in early recognition, risk assessment, physical monitoring,
safeguarding, and coordination of care with specialist services and multi-agency
partners.

2. Purpose

To ensure the prompt, safe, and evidence-based management of under 18s with
suspected or diagnosed eating disorders.

To comply with regulatory requirements and NICE NG69 guidance.

To detail processes for safeguarding, assessment, risk stratification, referral,
monitoring, and liaison with families and external agencies.

3. Duties

All Staff:

Part of  Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127) 

Identify possible eating disorder presentations.

(cid:127)  Escalate concerns and follow safeguarding pathways.

(cid:127)  Document assessments and actions fully using SystmOne/Ardens Templates.

GPs/Clinical Leads:

(cid:127)  Undertake full risk/medical assessments.

(cid:127)  Coordinate referrals and ongoing communication with specialist services and

safeguarding teams.

(cid:127)  Oversee quality assurance and compliance audits.

Site Lead:

(cid:127)  Ensure staff training and operational resources to assess health status.

(cid:127)  Support audit and version control.

4. Definitions

(cid:127)  Eating Disorder: Anorexia nervosa, bulimia nervosa, binge eating disorder, or
avoidant/restrictive food intake disorder as defined by DSM-5/NICE NG69.

Part of Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127)  Safeguarding: Processes to protect young people from neglect, abuse,

exploitation, as mandated in the Children Act 1989/2004 and Working Together
to Safeguard Children (2018).

(cid:127)  CNTW/Northumberland FT/Newcastle FT/CYPS/CAMHS: NHS and local

authority specialist services for children and young people’s mental health and
safeguarding.

(cid:127)  SystmOne/Ardens Templates: Electronic clinical templates for recording and
standardising history, risk, safeguarding, and referrals in general practice.

5. Process

5.1 Recognition and Initial Assessment

(cid:127) 

Identify at-risk patients through history, examination, growth monitoring, and
parental/third party concerns.

(cid:127)  Use the Ardens Eating Disorder Template in SystmOne for a structured

assessment, including:

(cid:127)  Eating and weight-loss patterns

(cid:127)  Growth chart centiles (WHO/RCPCH standards)

(cid:127)  Physical risk factors (as per MEED “traffic light” tool)

(cid:127)  Mental health and self-harm screening

Part of Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127) 

If a gastrointestinal cause for the weight loss is suspected, early referral to
secondary care, gastrointestinal services should be considered at the outset or
at any other time in the management of the patient if their condition changes and
suggests a gastrointestinal problem.

5.2 Safeguarding Assessment

(cid:127)  Assess all presentations for potential safeguarding concerns.

(cid:127)  Document and act on issues through the SystmOne Safeguarding Ardens

Template.

(cid:127)  Refer immediately to local authority safeguarding or CYPS when indicated,

following ‘Working Together to Safeguard Children’

5.3 Risk Stratification and Referral

(cid:127)  High-risk presentations (marked weight loss, bradycardia, electrolyte

disturbance) require urgent referral to Paediatrics

(cid:127)  For less acute cases, refer for specialist assessment local CYPS / CAMHS

Eating Disorders service (CNTW, Northumberland FT, as per locality) via usual
local protocols.

5.4 Multi-Agency Working

(cid:127)  Engage with all multi-disciplinary teams including mental health, paediatrics,

school health, social care and safeguarding teams. Attend meetings in person if
possible. If not deputise and if no-one can attend, ensure that a report is
provided to fully inform the meeting about activity in Primary Care.

Part of Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

(cid:127)  All contacts, actions and referrals are to be recorded using communication and

referral templates in SystmOne.

5.5 Ongoing Monitoring and Follow-Up

At regular intervals, repeat full risk/physical health assessments should be undertaken
in line with NICE guidance. The frequency should be individualized based on risk but
generally at least every 1-2  weeks initially, and as often as clinically indicated during
weight restoration or if there is any acute risk. Where and by whom this is taking place
should be agreed by all agencies, fully documented in the care records and outcomes
shared at multidisciplinary team meeting.

For mild to moderate severity (medically stable, no acute risk):

(cid:127)  Physical health monitoring includes:

(cid:127)  Regular weight and height checks

(cid:127)  Pulse, blood pressure (lying and standing), and temperature

(cid:127)  Assessment for physical signs of malnutrition or dehydration

(cid:127)  Blood tests (as indicated for electrolyte imbalance, renal/liver function)

(cid:127)  Frequency: At least every 1-2  weeks initially, with interval extended if stable.

High Severity / Increased Physical Risk (rapid weight loss, acute symptoms, or
physical instability):

Part of Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

Monitor more frequently:

NHS
Providing NHS services

(cid:127)  Vital signs (pulse, blood pressure, temperature) often several times a week or

daily if needed

(cid:127)  Daily or more frequent weight monitoring where medically indicated (especially

inpatient)

(cid:127)  Electrolyte and other relevant blood testing at least weekly or more often as

indicated

(cid:127)  ECG monitoring if at risk of cardiac complications (e.g., bradycardia, QTc
prolongation) or when taking medications that may affect cardiac function

(cid:127)  Monitor for signs such as fainting, cardiac arrhythmias, or new physical

symptoms.

Very High Risk (Medical Crisis/Emergency):

May require continuous inpatient monitoring (e.g., cardiac monitoring), urgent correction
of abnormalities, and intensive physical review ongoing as dictated by their status.

(cid:127)  Weight, height, BMI centile, BP, pulse, relevant blood tests

(cid:127)  Mental health, risk of self-harm/suicide

Document in SystmOne using the Ardens Templates and growth chart tools.

Part of Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

5.6 Supporting Families and Providing Information

(cid:127)  Offer information on both local and national support resources (self-help, family

support, parent groups).

(cid:127)  Liaise as needed with school nursing and community teams to support education

and ongoing care.

5.7 Training and Quality Assurance

(cid:127)  Ensure all staff access regular training in eating disorder management,

safeguarding, and the use of SystmOne/Ardens templates.

(cid:127)  Audit practice compliance with this policy annually, reporting findings to the

practice leadership team.

6. References

NICE NG69 Eating Disorders: Recognition and Treatment (2017)

Children Act 1989, 2004

Working Together to Safeguard Children (2018)

CQC Regulation 12: Safe Care and Treatment

Royal College of Psychiatrists: Medical Emergencies in Eating Disorders (MEED)
Guidance (2022)

Part of  Northumbria PRIMARY CARE

 NPC
49 Marine
Avenue

NHS
Providing NHS services

Part of  Northumbria P R I M A R Y  CARE
Response from Department for Health and Social Care (PDF)
Parliamentary Under-Secretary of State for 
Health Innovation and Safety 

39 Victoria Street 
London 
SW1H 0EU 

    19th December 2025 

HM Coroner Andrew Hetherington 
Coroner’s Office 
Northumberland County Council 
County Hall 
Morpeth 
Northumberland 
NE61 2EF 

Dear Mr Hetherington,  

Thank you for the Regulation 28 report of 23 June 2025 sent to the Department of Health 
. I am replying as the Minister 
and Social Care about the death of 
with responsibility for data and technology.       

Firstly, I would like to say how saddened I was to read of the circumstances of 

 death, and I offer my sincere condolences to the family and those who loved her. 

The circumstances your report describes are concerning and I am grateful to you for 
bringing these matters to my attention. Please accept my sincere apologies for the delay in 
responding to this matter. 

The report raises concerns relevant to the Department of Health and Social Care over there 
not being a single accessible system for weights, height and BMI, and a lack of clarity 
regarding oversight of care in an outpatient setting.   

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns. 

There are two BMI tools; one designed for use with adults aged 18 and over and the other 
for children and young people 17 and below.  

NHS England has prepared within its NHS.UK guidance, advice for parents and families on 
this topic (https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass-
index/calculate-bmi-for-children-teenagers) which states it should not be used if they have 

 
 
 
 
 
 
 
 
  
 
 
     
 
  
  
  
  
  
  
  
 an eating disorder and gives further advice for those who have (https://www.nhs.uk/mental-
health/feelings-symptoms-behaviours/behaviours/eating-disorders/advice-for-parents/). 

The plotting of height and weight for children commences at birth and results are entered 
into the parent held 'Red Book' and plotted on a centile chart which is intended to stay with 
the child throughout their lifetime. The digital Healthy Child Programme intended to digitise 
the 'Red book' commenced in 2019 with the goal of ensuring information could be shared 
more easily with parent and professionals alike. However, due to the extreme demands of 
COVID on the digital programmes and necessary reprioritisation, the digitisation of the Red 
Book was paused in 2021/22 but is again being discussed in NHS England in light of both 
the Single Patient Record (SPR) developments, described below, and incorporating newer 
technologies.  

Currently the Summary Care Record (SCR) contains a summary of a patient’s health 
information recorded on their GP record. This includes sharing information such as 
allergies, adverse reactions and medications for all patients - except where patients have 
opt-out – and for approximately 89% of the population also includes additional information 
relating to their medical, surgical and psychological history. The SCR is available to health 
and care professionals. Patients can access similar information about themselves via the 
NHS App along with all medical consultations. 

Secondary Care Providers can upload care plans and other clinical documents to the 
National Record Locator (NRL) developed and maintained by NHSE. The NRL is expected 
to integrate with local shared care records services and other suppliers which will result in 
broader and more consistent access for all health care providers. 

It is recognised by NHS England that the joining up of records to achieve easy access to all 
the information by clinicians and 'patients/their guardians' remains a challenge and NHS 
England with the Department of Health and Social Care is currently executing a substantial 
programme of work to increase the interoperability and sharing of all patient records, 
including medical history, investigations and vital patient measurements  (Blood pressure, 
Height and Weight etc) and would include centile charts in paediatric services. This has 
been outlined in the Governments 10 Year Plan and the ambition to develop a 'Single 
Patient Record. 

I agree that ensuring health and care professionals have access to a single source of digital 
information about the patients they are treating and caring for is vitally important to 
delivering the best care possible. The Department of Health and Social Care, and NHS 
England have programmes of work underway which should assist in preventing future 
deaths connected to this issue. 

NHS England is currently executing a substantial programme of work to increase the 
interoperability and sharing of all patient records, including medical history, investigations 
and vital patient measurements (Blood pressure, Height and Weight etc). This has been 
outlined in the Government’s 10 Year Health Plan and the ambition to develop a single 
patient record. 

 
 
  
  
  
  
  
 
 The Government’s 10 Year Health Plan commits to the delivery of a SPR. This will provide 
a comprehensive patient record, bringing together all of a patient’s medical records into one 
place which will help prevent unfortunate incidents where fragmented and disjointed 
information prevents treatment from being provided on time. 

Introducing a SPR will give clinicians all the data they need when treating patients. By 
having access to all relevant information about a patient, frontline staff will be able make 
more informed decisions and deliver the best care at the time it is needed. We are aiming 
for the record to begin processing information by 2028.  

Thank you for bringing these concerns to my close attention.   

Yours sincerely, 

Parliamentary Under-Secretary of State  
for Health Innovation and Safety
Response from Moorbridge School (PDF)
Moorbridge Alternative Education Partnership School 
Earsdon Road 
Shiremoor 
NE27 0HJ 
moorbridge@ntsss.org.uk  
www.moorbridgeschool.org.uk  

Andrew Hetherington 
H M Senior Coroner for Northumberland 
County Hall 
Morpeth 
Northumberland NE61 2EF 

Date: 10 August 2025 

Re: Regulation 28 Report to Prevent Future Deaths – Epiphany Hope Whiting 

Dear Mr Hetherington, 

I write on behalf of Moorbridge School in response to your Regulation 28 report dated 23 June 2025 
concerning the tragic death of 

. 

Firstly, please accept our heartfelt condolences to the family of the deceased. We recognise the 
profound loss and extend our deepest sympathies to all affected. 

Regarding your concerns outlined in section 5 of your report about the passage of information and 
communication, I wish to confirm that Moorbridge School takes safeguarding and information 
sharing with the utmost seriousness. In light of the issues raised, we have conducted a thorough 
review of our practices related to information sharing, safeguarding policies, and procedures. 

As part of our annual safeguarding refresher and other relevant training throughout the academic 
year , all staff have and will revisit and reinforce their understanding of these policies, with 
particular emphasis on timely and appropriate communication with relevant bodies and agencies. 
This training ensures that all members of our staff remain vigilant and proactive in sharing pertinent 
information to safeguard the welfare of all pupils. 

Moorbridge prides itself on fostering a culture of openness and collaboration with partner agencies, 
parents, and professionals to ensure the safety and wellbeing of every pupil. We are committed to 

Headteacher - 

Deputy Head – 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 continuous improvement and will continue to monitor and enhance our procedures to prevent any 
recurrence of communication lapses. 

We trust this response assures you of our commitment to safeguarding and effective information 
sharing. 

Yours sincerely, 

Deputy Head 

Headteacher - 

Deputy Head
Response from North East and North Cumbria Integrated Care Board (PDF)
Strictly Confidential 
Mr Andrew Hetherington 
HM Senior Coroner Northumberland 
County Hall 
Morpeth  
Northumberland 
NE61 2EF 

Dear Mr Hetherington 

NENC ICB 
Pemberton House 
Colima Avenue 
Sunderland 
SR5 3XB 

01 July 2025 

I write in response to your Regulation 28 Report to Prevent Future Deaths, dated 23 June 2025, 
concerning the tragic death of 
. I would like to extend my heartfelt condolences 
to her family and loved ones. We recognise that this must be an incredibly painful time, and we are 
deeply sorry for their loss. We have noted the contents of the report, and the matters of concern 
raised for a response from NHS North East and Cumbria Integrated Care Board, as follows: 

1.  Patient care records are held on different care record systems within the NHS which are 
not universally accessible to healthcare organisations, healthcare professionals or 
patients. There is not one accessible system for weights, heights, and BMI. 

The primary patient record is held within General Practice.  Locally GP practices use either 
SystmOne (provided by TPP) or EMIS (provided by Optum), depending on the practice's 
preference. All healthcare providers are expected to contribute key clinical patient information to 
these records, including height, weight, and BMI.  

In the North East and North Cumbria region, the majority of the large health and social care 
providers, including Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and 
Northumbria Healthcare NHS Foundation Trust, have access to primary care records through the 
Great North Care Record (GNCR).  The GNCR is supported by the national GP Connect service 
and provides a live view of records from an increasing number of health and care providers. This 
allows clinicians to view comprehensive patient data in real time, thereby supporting better-
informed clinical decisions. The type and extent of data accessible from each provider differs but 
ongoing development and increased provider participation are steadily improving the breadth and 
depth of available information. 

2.  There is a lack of clarity regarding oversight of care in an outpatient setting. There is no 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 specific guidance regarding oversight of care within the NHS. No one department or 
clinician has overall responsibility or accountability. 

Based on the timeline detailed in your report, it appears at the time of 
under the care of the dietician. The GP remains responsible for the overall medical care of the 
patient, whilst the dietician would manage the specific around the patient's weight. If the dietician 
had concerns it would be expected that these would be escalated to a senior dietician, the GP, or 
emergency care services, depending on severity.  

 death, she was 

Once a patient is under the care of a medical specialty they will have a named consultant, which is 
clearly recorded in correspondence between primary care, secondary care, and the patient.  

The General Medical Council's (GMC) Professional Standards on Delegation and referral (January 
2024) sets out the key expectations when a clinician refers a patient to another professional or 
service. The report is available via https://www.gmc-uk.org/-/media/documents/gmc-guidance-for-
doctors---delegation-and-referral_pdf-58834134.pdf.   The guidance states that patients should be 
informed of: 

•  Who is responsible for their overall care if this is not the referring clinician. 
•  The reasons for the referral and what should happen next. 
•  When they can expect to be seen by the new professional. 
•  Who to contact with any questions or concerns about their care.  

Furthermore, the GMC's Professional Standards for Leadership and Management (March 2012) 
outlines that most medical professionals work within multidisciplinary teams, where the primary 
focus is always the needs and safety of patients. While a formal leader (such as named 
consultant) is accountable for the overall performance of the team, the responsibility for identifying 
issues, addressing them, and taking appropriate action is shared collectively by all team members. 
The report is available via https://www.gmc-uk.org/-/media/documents/leadership-and-
management-for-all-doctors---english-48903400.pdf   

NHS England published the  Outpatient services: a clinical and operational improvement guide in 
September 2024, with the most recent update issued in May 2025.  This guide was developed in 
collaboration  with  the  Royal  College  of  Physicians  and  the  Patients  Association  and  provides  a 
national  framework  that  directly  addresses  the  lack  of  clarity  around  clinical  oversight  and 
accountability in outpatient care. It sets out clear expectations for providers to define and document 
clinical  responsibility,  implement  structured  handovers  and  escalation  protocols,  and  ensure  that 
every  patient  has  a  designated  clinician  or  team  responsible  for  their  care  at  each  stage  of  the 
outpatient journey. 

The guide also promotes the use of improvement analytics and local insight to monitor outcomes, 
identify risks, and support continuous learning. These measures are designed to reduce the risk of 
fragmented care, missed follow-ups, and harm due to unclear ownership of care. For patients, this 
means greater transparency, improved communication, and safer, more coordinated treatment.  

I  hope  this  response  addresses  the  concerns  outlined  in  your  report.  Please  do  not  hesitate  to 
contact me should you require any further information. 

 
 
 
 
 
 
 
 
 Yours sincerely, 

Executive Medical Director  
North East and North Cumbria ICB
Response from Northumbria Healthcare NHS Foundation Trust (PDF)
Patient Services and Quality Improvement 
Northumbria House 
Unit 7/8 Silver Fox Way 
Cobalt Business Park 
Newcastle upon Tyne  
NE27 0QJ 
Direct Line: (0191) 203 1356 
Email: inquests@northumbria-healthcare.nhs.uk  

Our ref: 

15 August 2025 

IN CONFIDENCE 
Mr A Hetherington 
HM Senior Coroner for Northumberland 
HM Coroners' Office 
County Hall 
Morpeth 
Northumberland 
NE61 2EF 

By email only: coroners@northumberland.gov.uk  

Dear Mr Hetherington 

REPORT TO PREVENT FUTURE DEATHS – INQUEST TOUCHING THE DEATH OF  

I  am  writing  to  you  in  response  to  the  Report  to  Prevent  Future  Deaths  (PFD)  served  on 
Northumbria Healthcare NHS Foundation Trust ("the Trust") on 23 June 2025, following the 
inquest into the death of 

.  

Your  report  was  also  sent  to  the  49  Marine  Avenue  GP  Practice,  Moorbridge  School, 
Department of Health and the Northeast and North Cumbria Integrated Care Board (ICB). I am 
writing to provide you with the Trust response to your concerns. For ease of reference, I have 
addressed each concern using the same numbering as referred to in the PFD Report. 

Concern  1:  The  Deceased's  weight  and  height  was  not  adequately  monitored  from 
November 2023. 

1.  During the course of the inquest, in written and/oral evidence, the Trust confirmed that the 

following actions had been completed to address this learning point:  

2. 

Internal management re-structure within Dietetics Service to introduce, and empower, a 
Community Team  Lead  to oversee  and manage all  the  outpatient  work  from triage  and 
clinic  capacity  to  reporting,  monitoring  and  planning.  This  facilitates  the  provision  of 
alternative  outpatient  offers,  including  home  visits  where  concern  is  raised  regarding 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 outpatient in-person attendance for any high risk, vulnerable patients. It allows improved 
oversight of staffing in terms of mobilisation of resource, training and support regarding 
escalation  pathways  and  case  reviews.  This  change  in  structure  was  implemented  in 
February 2025. 

3. 

Introduction of SystmOne as a clinical electronic records system for Nutrition and Dietetics 
outpatient consultations (Go Live of the Nutrition and Dietetics SystmOne unit was August 
2024) provides: 

3.1 Improved transparency and visibility of consultations with community partners including 

the GP. 

3.2 Improved, instant, communication with the GP via the system (less reliant on written 

letters to pass information). 

3.3 Improved visibility and tracking of patient weights, heights and clinical investigations. 
3.4 Improved, auditable, triage process via the SystmOne clinical system, including robust 
assessment,  by  senior  Dietetic  staff,  of  the  information  provided  and  appropriate 
direction/clinic allocation. 

4. 

Introduction  of  robust,  documented  clinical  supervision  was  launched  formally  at  the 
Nutrition and Dietetics Department meeting on 1 April 2025, within the Dietetics staffing 
structure and also with the Nutrition Team MDT from July 2025. 

4.1  Dietitians are now supported to critically review patients with very low  Body Mass 
Index’s  (BMIs)  to  consider  escalation  to  the  Nutrition  Team  MDT  and  MEED 
Oversight Group. 

4.2  Ongoing support is offered to staff in a variety of settings including routine monthly 
1:1s,  timetabled  clinical  supervision  sessions,  monthly  team  meetings  and  thrice 
weekly virtual huddles and this was in place prior to the death of 

. 

5.  Development of a Nutrition Multi-disciplinary Team (MDT) meeting which includes medical 
oversight  from  Gastroenterologists  for  complex and  vulnerable  Dietetic  outpatients  and 
mental health oversight from colleagues from the mental health Trust. The first meeting 
took place on 15 July 2025, scheduled to meet fortnightly and is on track with scheduling. 
The initial meetings were held with Dietetics and the Trust Gastroenterology consultants 
to review the current caseloads. Concerns may also be raised to this group outwith the 
scheduled meetings. This MDT will include mental health colleagues from going forward. 
The  terms  of  reference  are  currently  being  established  and  will  be  in  place  for  joint 
meetings to be scheduled from September 2025. 

6. 

Implementation of the Medical Emergencies in Eating Disorders (MEED) Oversight Group; 
this  group  has  been  meeting  every  6  weeks  since August  2024.  This  Group  includes 
colleagues  from  the  mental  health Trust  to  monitor  and  review  policies,  processes  and 
high-risk patient pathways and includes Executive Director oversight from both Trusts. The 
function  of  the  Oversight  Group  is  to  agree  and  formalise  operational  policies  and 
processes  rather  than  for  clinical  discussions.  However,  it  has  provided  opportunity  for 
discussing specific, existing, cases whilst the joint clinical MDT is established. 

7.  The  below  actions,  which  had  been  identified  before  the  Inquest,  but  were  not  yet 

complete, have since been progressed and put in place:  

8.  A Standard Operating Procedure has been developed and introduced from July 2025 for 
triage  and  management  of  suspected  Eating  Disorders/  Disordered  Eating  referrals  at 
triage and assessment. 

 
 
 
 
 
 
 
 
 
 9.  From August 2025, face to face appointments are now routinely offered by the Dietetics 
service  as  first  contact  for  any  patient  referred  for  nutritional  support  and  weight  loss 
(irrespective  of  the  cause).  If  telephone  contact  is  required  for  timeliness,  then  an  in-
person review appointment will then be offered after the initial telephone assessment. 

10.  Nutrition  and  Dietetics  staff  working  with  patients  from  16  years  and  above,  have  been 
advised by the Professional lead for Dietetics, at the monthly Adult team meeting on 25 
June  2025,  to  consider  the  national  MEED  guidelines  and ARFID  (Avoidant/Restrictive 
Food Intake Disorder) checklist to support the assessment of patients in the out-patient 
setting for current and future caseloads: 

10.1  MEED assessment tool link has now been embedded in the outpatient consultation 

record. 

10.2  Improved clinical awareness for any patient with a low BMI to be assessed for risk 

factors, irrespective of potential reason.  

10.3  Training  is  to  be  delivered  to  the  Nutrition  and  Dietetics  team  CNTW  dietetic 
colleagues, to support identification and management of eating disorders/disordered 
eating. There are a series of bookable webinars arranged for staff: 18 September 
2025;  15  January  2026;  23 April  2026  and  16  July  2026. In  addition,  a colleague 
from the mental health Trust will be attending the Nutrition and Dietetics department 
meeting  on  15  October  2025  to  give  an  update  and  training  to  all  staff  in  the 
department. A register will be taken, and the training resources will be supplied to 
any front-line staff member not in attendance. The Adult Dietetics team meeting on 
26 August 2025, has been specifically allocated for mental health training.  Feedback 
from a Trust-wide session on managing mental health in non-mental health settings 
and feedback on British Dietetic Association (BDA) eating disorders training will be 
shared at this meeting. 

11.  Internal  communications  and  safety  messages  have  been  cascaded  to  Trust  staff 
regarding the importance of obtaining accurate height and weight measurements in July 
2025,  including  frequency  of  assessment  and  clarity  on  how  the  measurements  were 
obtained, documented within the approved Trust-wide Nutrition and Hydration Policy. 

12.  The Trust are continuing to review all clinical systems and digital platforms to streamline, 
where possible, the reporting of weight and height and the interoperability of systems to 
provide assurance that measures are captured and reported centrally by all services. 

13.  Since  the  conclusion  of  the  inquest,  the  Trust  have  further  looked  at  systems  and 
processes in place and identified the additional actions, below, which remain ongoing: 

14. 

Introduction  of  a  Standard  Operating  Procedure  (SOP)  for  management  of  patients 
referred to the  Nutrition and  Dietetics  department  that  do  not  attend (DNAs)  or  are  not 
brought  to  appointments.  The  SOP  will  be  in  line  with  Trust’s  framework  for  non-
attendance and the Outpatient Steering Group recommendations. Referrals for patients 
with a very low weight and BMI who do not attend appointments require further discussion 
to agree  acceptable tolerances Trust-wide. This action will  be  raised  via the Outpatient 
Steering Group for consideration at the September 2025 meeting.  

15. 

Improve  process  and  management  of  transition  of  patients  (16-18  years)  within  the 
Nutrition and Dietetics service: 

15.1  Ensure patients are not ‘lost’ between paediatric and adult services. 
15.2  Age-appropriate assessments are used. 
15.3  Consider ‘transition clinic’ for adolescents and young adults. 

 
 
 
 
 
 
 
 
   
 This is ongoing work within the Dietetics leadership team to be finalised by the end of 2025 
and will be led by the Adult and Paediatric Dietetic team leads.  

16.  Mental Capacity Act (MCA) Training for all Nutrition and Dietetic staff was delivered during 
February and March 2025 by the Trust MCA Lead from the Safeguarding department. The 
intention of the training was to equip staff with the skills and knowledge to assess whether 
a patient had capacity to make decisions about their care and provided support to escalate 
concerns regarding  any patients  who may not  have  capacity.   The  confidence  to make 
assessments regarding mental capacity should support staff to navigate the appropriate 
escalation pathway for vulnerable, high-risk patients.  

17.  Introduction of regular, safeguarding supervision for the team from April 2025 to support 
safeguarding  decision-making  has  been  implemented;  the  second  session  will  be  in 
September 2025 and then twice yearly on a rolling basis. 

Concern 2: There was no referral to Gastroenterology. 

the  GP  monitored 

18.  The Falls & Syncope outpatient clinic contact letter, dated 20 November 2023, requested 
that 
into  the  Trust 
for  weight 
Gastroenterology specialty for further assessment. His Majesty's Coroner was concerned 
that this referral was not made by the GP, or directly by the referring Consultant in the Falls 
& Syncope team.  

loss  and  referred 

19.  During  the  inquest,  the  Trust  gave  oral  evidence  regarding  the  implementation  and 
cascading of the new consultant to consultant referral guidance. The Trust has adopted 
the Northeast North Cumbria (NENC) Consultant team to Consultant team referral policy 
via the  Northumberland and North  Tyneside GP/Provider  interface  group  organised  via 
NENC ICB. This will be adopted as a local policy and communicated to all clinicians within 
Northumbria by the Trust Policy group on behalf of the Executive Medical Director by the 
end of October 2025, following consultation/ratification at the Trust’s CPG (Clinical Policy 
Group). Primary Care colleagues also have access to the Trust’s Advice and Guidance 
service across the acute secondary care specialties to request advice and guidance on 
clinical cases, in this case including Gastroenterology.  

20.  The Trust allows inter-specialty referrals and also referrals ‘to’ and ‘from’ other provider 
NHS Trust’s where there is an appropriate repatriation and transfer of care required. 

21.  The Trust’s newly established Nutrition MDT would also consider and offer where more 
bespoke  and  specialist  clinical  nutrition  advice  and  support  is  required  for  other 
specialties. 

Concern 3: The Deceased was discharged from CAMHS in December 2023 without being 
seen in person, spoken to or weighed. 

22.  After  referral  to  CAMHS  on  20  November  2023,  an  appointment  was  arranged  for 
  on  13  December  2023.  This  appointment  was  cancelled  by  the  family,  but 
CAMHS made further contact via telephone with the family to establish if they had any 
concerns. CAMHS were told 
 did not want to attend, so no further appointments 
were made. 

23.  During  the  Trust's  investigation  and  the  inquest  process,  the  CAMHS  team  did  review 
their involvement with 
, and made the following changes to their systems and 
processes.  The  evidence  given  in  writing  and  at  the  inquest  on  these  matters  can  be 
summarised as follows: 

 
 
 
 
 
 
 
 
 
 
  
  
 24.  In  January  2025,  the 'Was  Not  Brought/Did  Not  Engage' CAMHs  guidance  was 
updated to include frequent cancellation guidance. This encompasses non-engagement 
of young people and children. In this situation, cases will be discussed within the CAMHS 
MDT and if deemed appropriate, escalated for consideration of a safeguarding referral or 
Early Help assessment (Early Help is explained in more detail below, in paragraph 31). 
The addition, the CAMHS guidance outlines that if concerns regarding weight loss and/or 
restricted dietary intake are identified in the referral and child or young person was not 
brought  or  fails  to  engage  in  appointments,  safeguarding  advice  and  referral  must  be 
considered. 

25.  Prior  to  a  decision  being  made  relating  to  discharge  if  a  child  or  young  person  will  not 
attend for a CAMHS assessment, a discussion within the CAMHS MDT will take place and 
every effort made to discuss with the referring clinician. Clarification will be undertaken at 
the  MDT  case  discussion  with  regard  to  dates  when  height  and  weight  measurements 
were taken, and by who, to support the decision-making process. These discussions focus 
on the potential risks and wider factors impacting on the health and wellbeing of the young 
person, including consideration as to whether a physical assessment has been completed 
or is needed. 

26. Following  the  inquest,  the  CAMHS  team  have  taken  the  below,  additional  actions  to 

further address the Coroner's concern: 

26.1  An  initial  awareness  raising  training  session  has  been  delivered  to  41  CAMHS 
Staff, on 15 July 2025, with a focus on assessment and risks of low weight and 
associated health needs. Further training is scheduled on 18 September 2025. 

26.2  Efforts are made to capture the voice of the child/ young person via phone contact 
and offer of appointment. This is undertaken for each assessment and forms part 
of the information gathering when a parent or carer is the primary contact. The non-
engagement guideline would be applicable in this instance. The non-engagement 
guidance outlines If a young person, parent or carer cancels an appointment and 
it  is  re-booked,  care  coordinators/Key  workers  will  assess  any  patterns  and  the 
potential risks. They will re-assess the plan of care as needed and inform relevant 
others depending on the level of concern. 

26.3  'Was  Not  Brought'  and  cancellation  rates  will  be  reviewed  through  caseload 
management (CLM) meetings with clinicians. The purpose is to review caseload 
numbers, was not brought and cancellation rates. Checks are also made that risk 
assessments  and  care  plans  have  been  completed.  Frequency  of  caseload 
management depends on the role of staff e.g. Consultant Psychiatrists have CLM 
every  3  months.  Other  members  of  staff  may  have  CLM  every  2  months.  This 
provides assurance that governance processes are being followed. 

 Concern 4: There was no in-person assessment by Dietetics, or escalation of care. 

27.  The Dietetics service aims to return to a pre-COVID out-patient position whereby face-to-
face appointments are offered as standard for all appointments. However, this is likely to 
require additional  resource  and a  commissioning  review.  In the  meantime,  face to  face 
appointments will be prioritised to all younger persons with red flags for low BMI.  

28.  The ability to track and report outpatient activity has been implemented via the SystmOne 
reporting  mechanism  to  support  future  discussion.  Home  visits  were  previously  only 
offered for frail, elderly, housebound patients as a result of commissioning arrangements 
and  issues  with  demand  for  the  service  significantly  outweighing  capacity.  Whilst  the 
commissioning and resource challenges remain, new management oversight of all Dietetic 
clinics has enabled greater mobilisation of the staffing resource from all areas within the 
Adult Dietetic service, optimising outpatient capacity and increasing flexibility of the offer.  

 
 
 
 
 
 
 29.  The standard referral criteria to the Dietetics service for nutrition support is patients with a 
BMI of less than 18.5 and/or 5-10% weight loss within 3-6 months. Higher risk patients 
(i.e. those referred with a BMI of less than 17.5, in line with MEED definitions for immediate 
risk to life) can now be offered a home visit, if it is felt that the patient won’t or can’t attend 
an in-person appointment at one of the Trust sites.  

30.  All higher risk patients will be offered a face-to-face appointment going forward and if a 
telephone contact is required to facilitate a timely intervention it will be followed by an in-
person  appointment  to  ensure  accurate  weight  and  height  is  recorded.  Face-to-face 
appointments for all patients who are not triaged as ‘higher risk’ are offered where possible 
and  would  be  based  on individual  clinical  need  and  may require  further  commissioning 
discussions.  

31.  The service is working on a SOP which will provide further assurance that patients are 
appropriately managed by the Dietetics Admin team. This SOP will include pathways to 
manage patient DNA’s, cancellations and patient/carer requests to change to a telephone 
call instead of an in-person contact, or to be discharged without further review. The Admin 
team will be able to task the clinicians via SystmOne with requests by patients to change 
appointments and clinicians will need to review the patient record to confirm and agree in 
writing  that  the  changes  are  acceptable.  This  SOP  will  be  cascaded  and  implemented 
following the Department meeting in October 2025. 

32.  The Trust acknowledges (e.g. because of patient choice) that it is not always possible to 
guarantee  all  first  appointments  are  face-to-face,  but  that,  all  first  attendance 
appointments should be face-to-face where clinically appropriate, and this standard has 
been set at the Outpatient Steering Group. 

Concern 5: The passage of information/communication. 

33.  In North Tyneside there is a Multi-Agency Safeguarding Hub (MASH) which was launched 
in 2017 (the Local Authority is the Lead Agency) and is the single point of contact to access 
services for children and young people and also the contact point where information can 
be  shared  where  there  are  identified  concerns  or  worries  from  partner  agencies.  The 
Trust's Safeguarding Department are fully integrated into the MASH as well as other key 
agencies such as Children's Services, Police, mental health services, Education, Primary 
Care and 0-19 school health.  

34.  The Community Paediatrician from the Trust was contacted by the Early Help Service in 

December 2022 about their views on ending the involvement of Early Help with 
and her family. The Trust Paediatrician opined that it was important for this to continue as 
it was beneficial for the whole family, as did 
 school, as it meant that there was 
coordination  between  all  of  the  agencies involved and school  still  had concerns  at  that 
time in relation to 
. The Early Help Service in North Tyneside Local Authority felt 
that the only issue outstanding was around Education and subsequently closed the Early 
Help/Family Partner involvement in April 2023. 

35.  If any Trust staff member or clinician has any safeguarding concerns or are worried about 
children or young people in their care, the first point of contact would be by seeking advice 
and support from the Trust's Safeguarding service or raising a safeguarding referral to the 
Local Authority,  which  would  go  via  the  MASH. Alternatively,  they  can  also  raise  their 
concerns directly with the Local Authority and during out of hours.  

36.  The Trust would then fully engage within any subsequent MASH records checks and any 
meetings  which  are  coordinated  via  the  Local  Authority  MASH  as  part  of  the  inquiry 

 
 
 
 
 
 
 
 
 
 
 process. This then allows all agencies to look at all information together, which may inform 
a wider picture of any concerns and risks and to form a plan. This forms a Signs of Safety 
Model  to  ensure  child  safety  and  wellbeing  and  involves  a  structured  approach  to 
assessment and planning to create safety for a child. The model does rely on each agency 
reporting concerns into the MASH.  

37.  Since the Coroner’s Inquest and receipt of the Regulation 28 report, the Trust have had 
further discussions with the ICB, and this case is being taken forward for further scrutiny 
and learning via the North Tyneside Safeguarding Partnership.  

38.  We are fully committed in working with our GP colleagues to ensure that any information 
that is shared between primary and secondary healthcare pathways and communication 
is implemented as part of the learning and actions from this case. This will be discussed, 
for action, at the NENC GP Provider interface group by October 2025. 

As a Trust, the safety and wellbeing of those we provide service to is paramount, and despite 
the  unfortunate  circumstances  in  which  your  concerns  have  arisen,  we  welcome  the 
opportunity His Majesty's Coroner has provided for us to further address the above issues. We 
also look forward to the responses from the Department of Health and the ICB. 

Yours faithfully 

Executive Medical Director and Consultant in Anaesthetics 
Signed on behalf of and in the absence of Dr Birju Bartoli, Chief Executive

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