Delay in treatment criticised by coroner

Delays in the assessment and treatment of a talented A-level student which “reduced the likelihood of a recovery” from anorexia were criticised by a coroner when the inquest resumed last week.

Delays in the assessment and treatment of a talented A-level student which “reduced the likelihood of a recovery” from anorexia were criticised by a coroner when the inquest resumed last week.

Eighteen-year-old Charlotte Robinson contracted a fatal bout of pneumonia when she was critically malnourished as a result of the eating disorder.

The sixth-former from Worstead, near North Walsham, developed a morbid terror of food and an obsession with exercise which saw her continue to do sit-ups even when her weight had plummeted to about six stone and she was too weak to climb stairs.

Her commitment to her A-level exams, her reluctance to become an in-patient and staff sickness and holidays led to delays in her treatment for a “dangerous” disease with a high mortality rate.


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Greater Norfolk coroner William Armstrong, in a narrative judgment, said he would make recommendations to NHS Norfolk and the Norfolk and Waveney Mental Health NHS Trust after the inquest heard there had been a five-week delay between her GP's referral and an assessment by a mental health nurse. There was a further month's wait after her initial assess-ment, by which point her body mass index (BMI) had plummeted to 12.6 - with 14 being the threshold for inpatient treatment.

She became “desperate” for help later that month and spent two days at the specialist Newmarket House Clinic in Norwich but her condition deteriorated and she was transferred to the Norfolk and Norwich University Hospital.

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She was fed through a nasal gastric tube and appeared to be making slow progress but then contracted pneumonia because her susceptibility was greatly increased due to her critical malnourishment.

Mr Armstrong said Miss Robinson, whose family learned after her death that she had attained four As in her exams, “fell prey to a dangerous illness which weakened her and finally claimed her life”.

He added: “Anyone sat in this court over the last two days could not have failed to be moved by this tragic story of a beautiful young woman who was literally wasting away”.

He commended her parents Chris and Pauline and said no family could have given her more support.

In reaching his narrative verdict, Mr Armstrong said: “Charlotte first displayed symptoms of anorexia no later than February 2007, when she received support from her GP.

“On April 30 she was referred by her GP to the mental-health team. There then followed an inappropriate delay in relation to this referral 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.”

He said he would make reports to both NHS Norfolk and the mental health trust and would make recommendations about GP referrals, cover during staff absence and for them to consider reviewing resources and services to those with eating disorders.

Giving evidence, NHS Norfolk's assistant director for commissioning Mark Weston said: “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.”

After the hearing, Mr Robinson said: “Society has lost a good citizen. Charlotte was a talented individual with a bright future. We, her family, have suffered an enduring loss.”

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