NHS trust promises improvements made after five-week delay led to anorexia death

November 7, 2008
by Staff Reporter

NHS trust mangers promise they have improved how referrals from GPs are handled. The pledge comes after a teenager died from anorexia following a five-week delay between referral and assessment.

A coroner yesterday criticised the “inappropriate” delays in the assessment and treatment of Charlotte Robinson, aged 18, from Norfolk, which “reduced the likelihood of a recovery”.

Ms Robinson contracted a fatal bout of pneumonia last year when she was critically malnourished.

Staff sickness was a factor in the delay, the inquest had heard.

A spokeswoman for the Norfolk and Waveney Mental Health Trust said after the inquest: "The systems regarding GP referrals and cover for staff absence...were improved and implemented during the summer of 2007."

Ms Robinson had first displayed symptoms of anorexia no later than February 2007, Greater Norfolk Coroner William Armstrong summarised in a narrative verdict.

He said: “On April 30 she was referred by her GP to the mental health team [at Norfolk and Waveney Mental Health Trust]. There then followed an inappropriate delay before Charlotte was seen by a mental health nurse on June 5.

"Following this initial meeting, when no comprehensive assessment was undertaken, and as a result of a failure of effective liaison there was then a further inappropriate delay before she was seen again on July 3, by which time her condition had further deteriorated.

"Her condition continued to deteriorate and on July 13, contrary to her earlier expressed views, she agreed to a referral to Newmarket House, a specialist facility for patients suffering from eating disorders.

"She was admitted to Newmarket House on July 20, by which time she was in a grave condition.

"On July 22, she became critically ill and was transferred to the Norfolk and Norwich University Hospital where, despite proper medical attention she died on August 8.

"The inappropriate delays in the initial referral to the mental health team and in arranging the second meeting with the mental health nurse reduced the likelihood of a recovery from the illness.”

Mr Armstrong said “no one individual was to blame” and concluded it would have been inappropriate to detain Miss Robinson under the Mental Health Act and to effectively force feed her.

NHS Norfolk's assistant director for commissioning Mark Weston said there were “very clear lessons” from the case.

"Within NHS Norfolk this issue has been taken extremely seriously. It will lead to change. My chief executive and deputy chief executive see it as a major priority to make changes in this area and it is being reviewed at the most senior level.”

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GPs should take responsibility

From: David Bowker, retired consultant psychiatrist, Manchester
Date: January 9, 2009

The option of GPs to refer only to a 'mental health team' is highly undesirable. It is not clear whether that was the case here. A GP should have the option of referring directly to a consultant psychiatrist in the type of case described. Nothing is better than a direct conversation with someone who will take responsiblity for following a case through.Teams are likely to have individuals of varying expertise and experience, and referral should be possible to that person, who in the opinion of the GP is best able to assess the patient. However it remains the responsibilty of the GP to pursue referrals considered urgent if unhappy with progress.

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