Case summary - Miss B
Miss B had a history of binge eating and induced vomiting from the age of 13 but had not sought help in the past. When she was in her mid-twenties she went to her GP, worried about the effect her condition was having on her six year old son.
In the autumn of 2012 Miss B was referred by her GP to an Eating Disorder Service where she was assessed by a specialist nurse. Although Miss B continued to see the nurse, she was unhappy with the therapy she was receiving; her therapy sessions were frequently cancelled or her therapist did not show up. Nor was there any liaison between the nurse and Miss B’s GP.
In the spring of 2013, the Trust responsible for the Eating Disorder Service contacted Miss B to invite her for a review of her care plan. Miss B declined, saying she did not think she had a care plan. She said the therapy had been inconsistent and had done ‘way more harm than good’. She felt she had been ‘dropped’ and was now struggling with her eating disorder. The Trust repeated its invitation but Miss B did not respond. Her mental health then deteriorated significantly.
A month later the Trust discharged Miss B back to the care of her GP with no information about her condition, what had happened while she had been in their care, no information about her risk status or what further monitoring she needed. Following the breakdown of her therapy, Miss B was unable to keep down food and she became depressed and emotionally volatile.
Two weeks later Miss B took a large overdose of prescription medication. She called a friend and was admitted to hospital but died the next day of heart failure.
As a result of our investigation, we concluded that the funding the Eating Disorder Service received was woefully inadequate. Miss B’s care was provided solely by the specialist nurse with no input from a psychiatrist or other professionals, despite this being contrary to good practice guidelines produced by the Royal College of Psychiatrists.
The actions and inaction of those involved in Miss B’s care meant that she found herself in a situation where she was at high risk but not receiving any support or monitoring, either from her GP or anywhere else. In fact, the service Miss B received from the Trust fell so far short of good practice that it would have been safer had she not received any service at all.
The specialist nurse failed to properly assess Miss B’s needs or the risks to her. Miss B’s therapy was not consistent and the nurse was working beyond her competence, without the support of line management or professional supervision, and in breach of some of the basic standards of nursing practice.
Opportunities were missed to provide Miss B with treatment that may have meant she would have lived. Her young son lost his mother. Both he, and Miss B’s own mother have to live with the distress of her loss, and not knowing whether she would have lived if she had received an adequate service.