Nichola Lomax
17 Dec 2021 · Coroner Joanne Kearsley · Manchester North
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. absence of understanding of MARSIPAN and its implementation in emergency treatment of an anorexic patient
“Inadequate Training of doctors and other medical professionals re eating disorders”
2. no pathways to obtain specialist eating disorder advice
“Accessing Specialist Advice”
3. community eating disorder service refuses patients with BMI below 14
“Referral Criteria for the Priory and Community Eating Disorder Service”
4. absence of Acute Liaison Psychiatry service at Fairfield General Hospital
“Lack of Critical Services”
5. unclear responsibility for community monitoring of high‑risk eating disorder patients
“Community Monitoring of patients with an Eating Disorder”
6. poor nursing documentation and lack of nutrition monitoring
“Nursing Input and Recording”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“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.”
This report
“Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited.”
Responses
2021-0433-Response-regarding-Nichola-Lomax.pdf ↗· Bury Clinical Commissioning Group
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.”