The death of an anorexic 44-year-old was caused in part by a “catastrophic collision of failures” by NHS services, a coroner has said.
Nichola Lomax, who suffered from bulimia and anorexia, weighed just three stone at the time of her death, on August 3, 2020.
She died at Fairfield General Hospital of liver failure as a result of her eating disorder, after having been discharged prematurely three times in the months prior to her death.
Joanne Kearsley, senior coroner for Greater Manchester North, concluded the tragedy was caused by “neglect”.
She said that one "stunning factor" of Nichola's case was that in the six months leading up to her death she was seen by more than 30 doctors.
Nichola, from Radcliffe, near Bury, Greater Manchester, had an 18-year history of the eating disorder.
Over the years had been admitted to hospital several times but by 2017 she had “disengaged” with specialist eating disorder services, according to the Manchester Evening News.
From that point on she was monitored by GPs at Radcliffe Medical Practice. Although she had regular appointments between June 2018 and June 2020, she was not weighed at the surgery and Ms Kearsley said "there was a lack of appropriate monitoring".
On January 15, 2020, Nichola's condition was life-threatening and she was admitted to Fairfield's A&E unit three times. According to Ms Kearsley, there was a “failure to recognise the severity of her condition" on each of these occasions resulting in her being discharged.
On June 1, Nichola attended her GP practice and was seen by an advanced medical practitioner, having been found in a grave physical condition by her sister, Kelly Cooke.
She went to Fairfield General Hospital and was admitted until June 3, when she was discharged. On June 5, Nichola again attended the GP practice and was referred to the Priory at Cheadle, a psychiatric hospital, where she was admitted and remained an inpatient until June 11.
During this time there were a number of failures, said Ms Kearsley, which contributed to Nichola’s death. These include poor nursing input, support and monitoring, a lack of understanding around the input required from psychiatry, failure to provide adequate discharge information to the GP and a lack of basic dietary advice or plan for treatment, such as whether Nichola should be put on a feeding tube.
On June 11 there was a conversation between Fairfield and the Priory. This conversation was misinterpreted, Ms Kearsley added, which resulted in Nichola being removed from the waiting list for a specialist eating disorder unit.
Ms Kearsley said that 'over and above any clinical failure', there was a failure to make sure there were appropriate pathways in place across the NHS in respect of MaRSipan national resources.
"And there is an absence of understanding among many clinicians as to where or how they can access specialist advice," she added.
Despite the best efforts of the advanced medical practitioner to help Nichola in the community while waiting for a bed to become available, her condition deteriorated and she was admitted to Fairfield General, where she died on August 3, of “the physical complications of the mental disorder anorexia nervosa and contributed to by neglect”.
The coroner said she would make a "Regulation 28 report" compiled to prevent further deaths.
Ms Kearsley said: "Nichola's death was a catastrophic collision of failures which in my opinion started long before any clinicians were involved with her."
She described Nichola as an individual who “wanted to get better” and told her family she would never be forgotten.
"Nichola will make a difference. She is now making a difference. You heard about a young girl admitted to A&E 10 days ago. That doctor dealt with that patient differently. Nichola will be part of the changes that will occur around eating disorder services across Greater Manchester."
Speaking in the wake of the inquest, Will Blandamer, executive director of strategic commissioning at Bury One Commissioning Organisation, said: “On behalf of Bury NHS Clinical Commissioning Group, I offer our sincere condolences to Nichola’s family.
"The CCG has acknowledged that there was a gap in services commissioned to reach into hospital and we are working closely with other stakeholders, including mental health and acute trusts, to close that gap and improve the eating disorder service offered.
"We are committed to the adult community eating disorder service expansion plan, a new service model with MaRSiPAN guidance as part of the core services, and it is anticipated that this will lead to significant improvements across Greater Manchester.”
A Priory Hospital spokesman said: “We would like to extend our sincerest condolences to Nichola’s family for their loss. This was a very challenging and complex case, involving a number of organisations.
"We are studying the coroner’s comments and recommendations and will consider very carefully what improvements can be made to assessing and communicating the criteria for the admission of eating disorder patients to our facilities. We will ensure that any lessons learned are fully embedded across our services.”
