Family says ‘lack of accountability’ left woman with eating disorder ‘at risk and vulnerable’

The coroner also heard that professionals in the Adult Social Care team had received no training specific to eating disorder issues, meaning they were ill equipped to pass accurate information to the specialists who were responsible for managing her treatment plan. This remains to be the case despite 4 years since Kiran’s death,

Further contradictory evidence was given about the chain of events leading up to Kiran’s death from 10th September 2019 onwards, with the Trust saying that they had told the Priory Group on Friday 13th September 2019 that she urgently needed an Eating Disorder bed, whereas the Priory Group claims they were told on 13th September that it was no longer needed.

Following Kiran’s death a review ‘to learn any lessons that might help to prevent any further incidents of this nature’ was carried out by Lancashire and South Cumbria NHS Foundation Trust, in which it identified a number of care and service delivery problems relating to the care that Kiran had received. 

The report detailed that Kiran had undergone two Mental Health Act assessments in the weeks before her death, both of which determined Kiran did not meet the threshold to be detained in hospital. An independent psychiatrist, instructed by the Coroner, gave evidence that he opined Kiran could have been detained on both occasions. The report also detailed that a specialist Eating Disorder bed was being sought for Kiran, and that there were plans to undertake a further Mental Health Act assessment when this was available.

However, in the absence of a specialist Eating Disorder bed, it was determined that she could not be detained under the Mental Health Act and she remained at her home, with no additional care or support put in place. 

Following the 1-week hearing, Senior Coroner Wilson delivered a short form conclusion of accidental death. The Coroner did also record on the Record of Inquest that certainly by 6th September 2019, when Kiran was assessed by two specialist doctors, for a Mental Health Act assessment, Kiran’s weight was declining.

The Coroner further stated that there was a failure to sufficiently assess the status of Kiran’s eating disorder during this assessment, and that the assessment was ‘inadequate’. The Coroner found that Kiran’s presentation at tat time justified a period of detention in a hospital setting, where her declining weight could have been stabilised, and went on to describe the decision not to detain her as a ‘missed opportunity’.

The Coroner also recorded that when social care professionals attended Kiran’s home on 10th September 2019 and weighed her, her weight had reduced further. He concluded that a decision was then taken to seek an inpatient, specialist eating disorder bed for Kiran.

However, he further found that professionals could, at that time, have convened an ‘immediate’ Mental Health Act assessment which may have led to her admission to a general acute, or medical, bed in hospital, rather than ‘waiting for the specialist eating disorder bed to materialise’. 

The Coroner agreed with Kiran’s family, as stated at the time, that there was a ‘real and imminent risk to Kiran’s life’, and that required urgent action to be taken. This did not occur.

The family have since said that they believe that a lack of accountability, the ongoing refusal to engage them in decisions about the care that Kiran needed, and a lack of training, understanding and awareness around Eating Disorders contributed to her death. Further, there were serious concerns raised by the family that they had been left in the dark whilst Kiran deteriorated despite ongoing attempts to seek help for her.

The family do not feel that they were taken seriously.

They say that they are particularly concerned about Blackpool Council’s response to the tragedy after Kiran’s sister, Simran, received a letter in 2021 saying that they HAD NOT reviewed their involvement in Kiran’s case to review its practices in a bid to learn lessons, and that they would not do so until the inquest had concluded. This was a concern also shared by the Coroner.

Speaking on their behalf following the hearing their lawyer, Aimee Brackfield from Simpson Millar Solicitors, said they were ‘utterly heartbroken’ by the catalogue of failings in the care that had come to light during the inquest.

The family had also been left disappointed that it took a Coroner to direct the Council to take necessary steps to safeguard life in the future, but were encouraged to see the Trust has taken active steps to address resourcing and training issues and hopes this will be imbedded correctly and will be ongoing.

Aimee added that the family are now desperate for lessons to be learnt, particularly in relation to how the complex needs of people with eating disorders are managed by the various relevant authorities – including ensuring that all staff receive training on the Medical Emergencies and Eating Disorders guidance which references an over reliance by professionals on ‘GDPR’ issues, preventing them from speaking to families.

The family have been very concerned by such comments, as individual data rights should never prevent professionals seeking input from the family, and indeed the MARSIPAN and subsequent MEED guidance encourage that, which they feel only seeks to reinforce the need for bespoke and specialist and ongoing training.