2025-0314
23 Jun 2025 · Coroner Andrew Hetherington · Northumberland
The coroner's concerns
1. lack of weight monitoring
“The deceased's weight was not adequately monitored from November 2023”
2. no referral to gastroenterology
“There was no referral to gastroenterology”
3. discharge without face to face assessment
“The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed”
4. lack of in person dietetics assessment
“There was no in person assessment by dietetics or escalation of care”
5. information not shared appropriately
“I am concerned that this information was not shared to an appropriate body”
6. no unified records system for weight metrics
“I am concerned there is not one accessible system for weights, heights and BMI”
7. lack of oversight in outpatient care
“There is a lack of clarity regarding oversight of care in an outpatient setting”