Lack of training on eating disorders and MARSIPAN implementation
NHS England received 2 coroners' reports about this hazard between 3 Mar 2021 and 17 Dec 2021.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Evidence from a wide range of clinicians who had engaged with [the deceased] in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHSEI issued national guidance in August 2019 which sets out a clear expectation that CED services develop integrated pathways with primary care and where responsibility for medical monitoring sits. The guidance outlines that”
Stated timescale: August 2019
Web search (Tavily): No evidence found either way
integrating-care-next-steps-to-building-strong-and-effective ... ↗- 9 months laterIdentical hazardConfidence 0.95 · higha different coroner
“Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“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.”
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2021Nichola Lomax9 months after Averil Hart · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight inadequate training of doctors and other medical professionals regarding eating disorders, particularly concerning the MARSIPAN guidance.
Averil Hart · 3 Mar 2021
“Evidence from a wide range of clinicians who had engaged with [the deceased] in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above.”
Original on judiciary.uk ↗ Nichola Lomax · 17 Dec 2021
“Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NHSEI issued national guidance in August 2019 which sets out a clear expectation that CED services develop integrated pathways with primary care and where responsibility for medical monitoring sits. The guidance outlines that”
Stated action · timescale: August 2019
“NHSEI issued national guidance in August 2019 which sets out a clear expectation that CED services develop integrated pathways with primary care and where responsibility for medical monitoring sits. The guidance outlines that”
What happened next: No evidence found either way
The NHS England document outlines integrated care systems and their aims but does not specify a timeline for when integrated care pathways were to be developed or implemented.
“It signals a renewed ambition for how we can support greater collaboration between partners in health and care systems to help accelerate progress in meeting our most critical health and care challenges. It details how systems and their constituent organisations will accelerate collaborative ways of working in future, considering the key components of an effective int”
No evidence found does not mean the action did not happen.
Stated action
“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.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2021 | 0.73 | 0.55 | Identical · 0.95 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.