Systemic Investigation
Partially Accepted
Not Complied
Ignoring the alarms: How NHS eating disorder services are failing patients
Systemic investigation into NHS eating disorder services, finding patients failed by inadequate training, poor transition from child to adult services, lack of coordination and insufficient specialist provision. PACAC follow-up (2019) found 'not enough action' taken. PHSO wrote to ministers again in March 2024 calling for eating disorder care to be made a priority.
5 recommendations
4 with response
Recommendations
General Medical Council
Rec 1
Partially Accepted
The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders.
Partially accepted:
Government response via PACAC (CP 105, August 2019) committed to improvements. PACAC found in 2019 that 'not enough action has been taken to implement them fully across the NHS risking avoidable deaths'.
13 August 2019
Department of Health and Social Care / NHS England
Rec 2
Partially Accepted
The Department of Health and NHS England should review the existing quality and availability of adult eating disorder services to achieve parity with child and adolescent services.
Partially accepted:
Government claimed parity had been achieved. PACAC found this claim 'disturbing' when it 'clearly had not' been achieved. PHSO wrote to Minister for Mental Health again in March 2024 calling on government to make eating disorder care a priority.
13 August 2019
NICE
Rec 3
Pending
NICE should consider including coordination as an element of their new Quality Standard for Eating Disorders.
Health Education England
Rec 4
Partially Accepted
Health Education England should review how its current education and training can address the gaps in provision of eating disorder specialists we have identified.
Partially accepted:
Health Education England has since been merged into NHS England (1 April 2023). Government response via PACAC committed to reviewing training but PACAC found 'further action' was needed.
13 August 2019
NHS Improvement / NHS England
Rec 5
Partially Accepted
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Partially accepted:
NHS Improvement merged into NHS England (1 July 2022). The Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework from autumn 2023, giving trusts more autonomy over investigation decisions.
13 August 2019