A 17-year-old girl with autism died in an advanced state of starvation after a series of missed opportunities by NHS services, an inquest has ruled. The teenager, who weighed just over five stone (32kg) at the time of her death, was admitted to Northumbria Specialist Emergency Care Hospital in an extremely malnourished state.
Senior coroner Andrew Hetherington identified seven areas of failure in a prevention of future deaths report following the inquest on June 19. He said opportunities to recognise her weight loss and escalate care were missed from November 2023 onward, although it was not possible to say whether earlier intervention would have prevented her death.
The coroner criticised a lack of face-to-face monitoring of the girl's weight after November 2023 and the failure to refer her to specialist gastroenterology services. He noted confusion over consultant-to-consultant referrals, with a consultant physician writing to the GP asking them to arrange a referral despite updated NHS guidance allowing direct referrals.
Further failings included the girl's discharge from child and adolescent mental health services (CAMHS) in December 2023 without being seen in person, spoken to, or weighed. Despite a consultant's referral highlighting urgency, an appointment was cancelled after the mother said her daughter disliked the service. The coroner said there was no exploration of why the girl refused to engage.
By March and April 2024, her weight had fallen below 32kg, with a BMI of 12.9. The coroner expressed concern that staff did not follow Medical Emergencies in Eating Disorders (MEED) guidelines and failed to escalate care. He also highlighted poor information sharing between the GP surgery, hospital trust, and Moorbridge School, noting that the mother had raised concerns about her daughter's eating habits as early as February 2023.
The coroner called for a single accessible NHS system for recording weight, height, and BMI, and raised concerns about a lack of oversight of outpatient care. NHS organisations involved in her care admitted it was not at the standard anyone would expect.
