Teen girl dies in NHS hospital in 'advanced state of starvation' weighing just 32kg

A teen girl died after being admitted to an NHS hospital in "an advanced state of starvation", an inquest has heard.

The 17-year-old girl, who hadautism, was taken to A&E at the Northumbria Specialist Emergency Care Hospital after a string of opportunities were missed to save her life, an inquest has ruled. Northumberland senior coroner Andrew Hetherington outlined seven areas of NHS failures in a formal reports following the inquest on June 19.

The coroner found: "[She] died as a result of the effects of extreme malnourishment. Opportunities to recognise the weight loss and escalate care were missed after November 2023. It is not possible to say whether the outcome could have been prevented with earlier escalation."

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In a "prevention of future deaths" notice, he listed the areas where improvements were needed to stop similar instances happening again.

NHS organisations involved in her care agreed, saying it was "not at the standard anyone would expect".

The coroner told the hospital trust and the girl's GP he had concerns about a lack of "adequate" monitoring of the girl's weight in the months leading up to her death. He also questioned why she wasn't referred on to a specialist gastroenterology service.

Senior Coroner Hetherington wrote: "I am concerned there was no physical or face to face monitoring of the deceased’s weight from November 2023."

The coroner added: "There was no referral to gastroenterology. I am concerned there is confusion as to the guidance on Consultant-to-Consultant referrals. The Consultant Physician wrote to the GP saying, 'please monitor weight loss and refer into gastroenterology services for further assessment'."

This is, the coroner explained, despite the fact that by this time - autumn 2023 - NHS guidance had changed so that "consultants could and should" refer patients to other speciality areas themselves if necessary. But this change had yet to be shared with the relevant consultants.

The coroner also raised concern that the girl was discharged by child and adolescent mental health services without being seen in person, spoken to, or weighed. This is despite a consultant's referral highlighting how she should be seen "urgently".

Though she was offered an appointment, her mother told NHS staff that her daughter "hated" the service and might refuse to engage. An appointment was cancelled. The coroner said there had been "no exploration" of why the girl would not engage with services - and she was discharged on December 12 2023.

Senior Coroner Hetherington added: "I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly. I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments."

The coroner also said that by March and April 2024 - when the girl's weight had fallen to less than 32kg - that: "I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines." At that stage, the girl's BMI was thought to be just 12.9.

Mr Hetherington has also highlighted issues between the GPs' surgery, the hospital trust and Moorbridge School as to how information was shared. He explicitly referred to a conversation the girl's mother had in February 2023 "where she described the deceased having significant problems with her eating habits, losing weight and refusing to eat foods that would be good for her and put weight on her".

The coroner has also highlighted his fear that when it comes to health records, there is "not one accessible system for weights, heights and BMI" within the NHS, while in writing to both the integrated care board (ICB) and DHSC he highlighted what he found to be an issue when it comes to accountability.

He said: "There is a lack of clarity regarding oversight of care in an outpatient setting. The Patient Safety Incident Investigation report identified that there was a lack of oversight of care.

"The [Serious Incident] report comments that the referrals between services were all appropriate but it was unclear who had oversight of all the care and that the investigation team felt that oversight was unclear and that arrangements around risk assessment escalation safeguarding and GP involvement could have been better through improved communication."

"I heard that in an inpatient setting there are key NHS standards set around what was described as “the name at the end of the bed” which healthcare professionals work within.

"I am concerned that in an outpatient setting there is no specific guidance regarding oversight of care within the NHS. No one department or clinician has overall responsibility or accountability."

The relevant bodies now have until August 18 to respond to the issues raised. Northumbria Primary Care - the organisation which runs the 49 Marine Avenue GP surgery in Whitley Bay - is a subsidiary of the Northumbria Healthcare NHS Trust.

A Northumbria Healthcare NHS Trust spokesperson said: "We would like to offer our sincere condolences to the family and loved ones. We acknowledge that some of the care across the system in this case was not at the standard anyone would expect.

"We cannot discuss this in detail due to patient confidentiality, but we are committed to learning the lessons from what happened and making sure they are addressed, working alongside colleagues across the healthcare system. We will be sharing our written response with the coroner with the given timeframe."

A spokesperson for the ICB - which commissions our health services - said: "Our thoughts are very much with the patient's family and friends after their sad loss. We take these concerns very seriously and have provided a detailed response to the coroner."

The DHSC and Moorbridge School have been approached for comment.