“A catastrophic collision of failures” – Neglect in an Article 2 Inquest into the death of Nichola Lomax at Fairfield Hospital, Bury

Nichola Jane Lomax v Northern Care Alliance, Greater Manchester Mental Health Trust, the Priory and Pennine Care NHS Trust.   

Sam Harmel 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.  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.  In addition, there had been a failure by Fairfield Hospital 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, a failure to complete nutrition and fluid balance charts and a lack of understanding around 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 to ensure that appropriate pathways were in place across the NHS in respect of MARSIPAN.  This was exacerbated by a failure to commission and provide a fully supported Community Eating Disorder Service across areas in Greater Manchester or to commission a Liaison Psychiatric Service 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. 

Sam Harmel was instructed by Kelly Darlington of Farleys Solicitors.


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