James Frankish

9 Oct 2019 · Coroner Elizabeth Didcock · Nottinghamshire

The coroner's concerns

1. Pica leading to bezoar formation
“Professionals who cared for [the deceased] did not understand how dangerous Pica can be, ie that it carries significant health risks, including the development of a bezoar”
2. lack of guidance for Pica identification and risk management
“That there is no national or professional guidance about identification, assessment and management of Pica, with no guidance about how best to understand and manage risk in this condition”
3. lack of monitoring for bezoar development in Pica
“That there is no national or professional guidance for monitoring for the possible development of a bezoar in an individual who has Pica”