Anorexia Schoolgirl Died Following Delay in Treatment

She ruled that her death was contributed to by delay in accessing effective inpatient treatment and physical health monitoring prior to September 2005. The Coroner is concerned at the lack of funding for treatment of teenage anorexiasufferers.

Emma Carpenter died aged 17 at the Queen’s Medical Centre in Nottingham on 22nd December 2006. The Coroner described her as a bright, hard working and talented young woman capable of giving and inspiring strong friendship and love who had much to offer to society.

The Coroner urged all parents, relatives, healthcare professionals and teachers to be highly vigilant for signs and symptoms of Anorexia Nervosa amongst the children and young people in their care. Describing it as:

“A devastating illness capable of causing immense distress and physical harm and which feeds upon the secrets and deceptions it creates.”

She urged young people, especially adolescent girls, to beware of the dangerous lure of the desire to be thin, inflicted upon them relentlessly by the many irresponsible producers of unnatural images of women, and to resist the temptation to falsely define their worth by reference to the size or shape of their bodies.

Paul Balen consultant at Freeths LLP and solicitor for Emma’s Father Noel Hand said:

“The Coroner’s careful and detailed review of this tragic death followed two previous inadequate reviews, first bythe Trust and then by the Health Ombudsman. The comprehensive analysis of the evidence heard by the Coroner, her conclusions and recommendations should be carefully studied by all those concerned with the treatment of anorexia victims. Mr Hand hopes that if this is done further anorexia related deaths will be avoided.”

Paying tribute to all involved in their creation and implementation of the MARSIPAN (Management of Really SickPatients with Anorexia Nervosa) Guidelines which since Emma’s death has transformed Anorexia Nervosa care and has enabled Psychiatrists, Paediatricians, GPs and Mental Health Nurses to work together more effectively, the Coroner expressed concern at the:

1. Lack of government commitment to long term funding of the Eating Disorder Service;
2. National lack of provision of inpatient beds for mentally ill children and adolescents;
3. Lack of funding for school nurses;
4. Gaps in clinical knowledge and legal-services in Eating Disorders at Bassetlaw and District General Hospital; and
5. Lack of clear connections between the education system and mental health MDTs, in the light of the reduction in the state school nursing service.

The Coroner is to write to the relevant organisations which have power to take action to remedy this.