Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of training on eating disorders and MARSIPAN implementation
The earlier warning
Averil Hart · 3 Mar 2021 · Sean Horstead, Cambridgeshire and Peterborough
“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.”
What was promised
Stated action 1 · response to Averil Hart (3 Mar 2021) · stated 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”
judiciary.uk/…/2021-0058-Response-from-NHS-England-and-NHS-Impr…
What recurred
- 17 Dec 2021 · Nichola Lomax · Joanne Kearsley · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · Nichola Lomax · 17 Dec 2021
“Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited.”
What happened next
No evidence found either way · stated action 1
“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”
integrating-care-next-steps-to-building-strong-and-effective ... · england.nhs.uk/…/integrating-care-next-steps-to-building-strong…
No evidence found does not mean the action did not happen.