“A Catastrophic Collision of Failures” – Neglect and Systemic Failures in an Article 2 Inquest into the Death of Nichola Lomax at Fairfield Hospital, Bury.

Organisations involved: Northern Care Alliance (“NCA”), Greater Manchester Mental Health Trust (“GMMH”) , the Priory and Pennine Care NHS Trust.   

Kelly Darlington and her team represented the family of Nichola Lomax at an inquest into her death.  Nichola had a long standing history of what was described by various specialists, as one of the most serious eating disorder cases they had encountered.

On 13th January, 23rd March and 28th April 2020 Nichola attended A&E at Fairfield General Hospital in Bury.  On each of these occasions there was a failure to recognise the severity of her condition and admit her for a period of medical stabilisation which under the NCA trust re-feeding policy should have been for between 4-7 days.  In addition there had been a failure by the Trust to disseminate guidance relating to the Management of Really Sick Patients with Anorexia Nervosa (“MARSIPAN”).  This meant the guidance was not known or followed on any of Nichola’s admissions and on each of these occasions she was discharged.

Between 1st June and her death on 3rd August 2020, there were gross failures in the provision of basic care afforded to Nichola.  There was a failure to admit her to hospital for a period of medical stabilisation, a lack of basic dietetic advice, a lack of clarity as to the treatment plan, poor nursing input, support and monitoring including a failure to complete nutrition and fluid balance charts and a lack of understanding around the input required from Psychiatry

The Coroner concluded that on the balance of probabilities all of the above failings probably caused or contributed to Nichola’s death.  Further, that over and above any clinical failures there has been a failure ensure there are appropriate pathways in place across the NHS in respect of MARSIPAN and a there was an absence of understanding for many clinicians as to where or how they can access specialist advice.  This was exacerbated by a failure to commission and provide a fully supported Community Eating Disorder Service across areas in Greater Manchester including Bury or to commission any Liaison Psychiatric Services within Fairfield Hospital contrary to NICE guidance.

The Coroner concluded that Nichola died of the physical complications of the mental disorder, anorexia nervosa contributed to by neglect.  The Coroner issued a Regulation 28 report to Prevent Future deaths to 10 different organisations including the Secretary of State for Health & Social Care, NHS England, the Chief Executive of Health Education England, The Priory Group, Northern  Care Alliance, Greater Manchester Mental Health NHS Foundation Trust, Bury Clinical Commissioning Group, Greater Manchester Health and Social Care Partnership and the Chief Executive of Academy of Medical Royal Colleges, Faculty of Eating Disorders Royal College of Psychiatrists.

Sam Harmel of Kings Chambers was instructed as Counsel in this inquest.