Source · Prevention of Future Deaths

REDACTED

Ref: 2025-0314 Date: 23 Jun 2025 Coroner: Andrew Hetherington Area: Northumberland Responses identified: 5 / 5 View PDF

Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.

Date 23 Jun 2025

56-day deadline 8 Sep 2025 est.

Responses identified 5 of 5

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

To Marine Avenue Surgery and Northumbria Healthcare NHS Foundation Trust
1.The deceased’s weight was not adequately monitored from November 2023. I am concerned there was no physical or face to face monitoring of the deceased’s weight from November 2023. I heard about the importance of physical eye to eye contact and examination on a face-to-face basis so that one can see evidence of the skin, properly see the patient’s face and when doing the height and weight asking for the removal some of their clothing to assess muscle mass.
2.There was no referral to gastroenterology I am concerned there is confusion as to the guidance on Consultant-to-Consultant referrals. The Consultant Physician wrote to the GP saying, "please monitor weight loss and refer into gastroenterology services for further assessment". The GP was aware of guidance regarding Consultant-to-Consultant Referrals that had been updated in October 2023 so that Consultants could and should be directly referring patients themselves to another speciality if there was a clinical reason to do so, rather than passing that task back to the GP. The Consultant Physician told me the guidance was not cascaded down to trust level until December 2023 after the Consultant Physician saw the deceased and that the final guidance has not yet been received. To Northumbria Healthcare NHS Foundation Trust
3.The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed The second referral to CAMHs was following the Consultant Physician’s letter dated 20 November 2023. The request was “I would be grateful if you could see this young girl urgently for advice with regards to oral intake. She has lost weight over a number of months and clinical history as outlined above”. The deceased was offered an appointment in keeping with the 4-week national waiting timescale for CYP with an eating disorder. Contact was made with mum on 24 November and an appointment offered for 13 December 2023. During the call Mum told staff the deceased “hated CAHMS so might kick off and refuse to come”. Mum cancelled the appointment on 11 December 2023. CAMHs contacted mum by telephone on 12 December 2023. Mum said that the deceased was not aware that she had been referred to CAMHs, was not willing to attend. Again, there was no exploration as to why that was the case and no direct contact with the deceased. (a) I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly. (b) I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments.
4.There was no in person assessment by dietetics or escalation of care The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations. At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17. On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4. The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.

Red or high risk would be a BMI less than 13. The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9 I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines. To Marine Avenue Surgery, Northumbria Healthcare NHS Foundation Trust and Moorbridge School.
5.The Passage of information/communication Communication: I heard about the importance of the passage of information. During the course of the inquest a witness was taken to the SEN chronology and an entry dated 1 March 2024 which refers to a conversation with the deceased’s mother on 29 February 2024 where she described the deceased having significant problems with her eating habits, losing weight and refusing to eat foods that would be good for her and put weight on her. I am concerned that this information was not shared to an appropriate body. To North East and North Cumbria Integrated Care Board and Department of Health
6.One records system - weights, heights and Body Mass Index (BMI) I heard that patient care records are held on different care record systems within the NHS which are not universally accessible to healthcare organisations, healthcare professionals or patients. I heard good examples of accessible records such as the Great North Care Record (GNCR) and Systm0ne operated by some in Primary Care. I am concerned there is not one accessible system for weights, heights and BMI.

To North East and North Cumbria Integrated Care Board and Department of Health
6.Oversight of care in an Outpatient setting There is a lack of clarity regarding oversight of care in an outpatient setting. The Patient Safety Incident Investigation report identified that there was a lack of oversight of care. The early help assessment team were stepped down in 2022 and they may have been the appropriate team to maintain oversight of care. The SI report comments that the referrals between services were all appropriate but it was unclear who had oversight of all the care and that the investigation team felt that oversight was unclear and that arrangements around risk assessment escalation safeguarding and GP involvement could have been better through improved communication. I heard that in an inpatient setting there are key NHS standards set around what was described as “the name at the end of the bed” which healthcare professionals work within. I am concerned that in an outpatient setting there is no specific guidance regarding oversight of care within the NHS. No one department or clinician has overall responsibility or accountability.

Responses

5 respondents

North East and North Cumbria Integrated Care Board Integrated Care Board

1 Jul 2025 PDF

Noted

The North East and North Cumbria Integrated Care Board acknowledges the concerns, noting the existing systems for patient record sharing via the Great North Care Record and the responsibility of medical professionals within multidisciplinary teams. They also refer to NHS England guidance on outpatient services. (AI summary)

View full response

Dear Mr Hetherington

I write in response to your Regulation 28 Report to Prevent Future Deaths, dated 23 June 2025, concerning the tragic death of . I would like to extend my heartfelt condolences to her family and loved ones. We recognise that this must be an incredibly painful time, and we are deeply sorry for their loss. We have noted the contents of the report, and the matters of concern raised for a response from NHS North East and Cumbria Integrated Care Board, as follows:

1. Patient care records are held on different care record systems within the NHS which are not universally accessible to healthcare organisations, healthcare professionals or patients. There is not one accessible system for weights, heights, and BMI.

The primary patient record is held within General Practice. Locally GP practices use either SystmOne (provided by TPP) or EMIS (provided by Optum), depending on the practice's preference. All healthcare providers are expected to contribute key clinical patient information to these records, including height, weight, and BMI.

In the North East and North Cumbria region, the majority of the large health and social care providers, including Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Northumbria Healthcare NHS Foundation Trust, have access to primary care records through the Great North Care Record (GNCR). The GNCR is supported by the national GP Connect service and provides a live view of records from an increasing number of health and care providers. This allows clinicians to view comprehensive patient data in real time, thereby supporting better- informed clinical decisions. The type and extent of data accessible from each provider differs but ongoing development and increased provider participation are steadily improving the breadth and depth of available information.

2. There is a lack of clarity regarding oversight of care in an outpatient setting. There is no

specific guidance regarding oversight of care within the NHS. No one department or clinician has overall responsibility or accountability.

Based on the timeline detailed in your report, it appears at the time of death, she was under the care of the dietician. The GP remains responsible for the overall medical care of the patient, whilst the dietician would manage the specific around the patient's weight. If the dietician had concerns it would be expected that these would be escalated to a senior dietician, the GP, or emergency care services, depending on severity.

Once a patient is under the care of a medical specialty they will have a named consultant, which is clearly recorded in correspondence between primary care, secondary care, and the patient.

The General Medical Council's (GMC) Professional Standards on Delegation and referral (January
2024) sets out the key expectations when a clinician refers a patient to another professional or service. The report is available via https://www.gmc-uk.org/-/media/documents/gmc-guidance-for- doctors---delegation-and-referral_pdf-58834134.pdf. The guidance states that patients should be informed of:

• Who is responsible for their overall care if this is not the referring clinician.
• The reasons for the referral and what should happen next.
• When they can expect to be seen by the new professional.
• Who to contact with any questions or concerns about their care.

Furthermore, the GMC's Professional Standards for Leadership and Management (March 2012) outlines that most medical professionals work within multidisciplinary teams, where the primary focus is always the needs and safety of patients. While a formal leader (such as named consultant) is accountable for the overall performance of the team, the responsibility for identifying issues, addressing them, and taking appropriate action is shared collectively by all team members. The report is available via https://www.gmc-uk.org/-/media/documents/leadership-and- management-for-all-doctors---english-48903400.pdf

NHS England published the Outpatient services: a clinical and operational improvement guide in September 2024, with the most recent update issued in May 2025. This guide was developed in collaboration with the Royal College of Physicians and the Patients Association and provides a national framework that directly addresses the lack of clarity around clinical oversight and accountability in outpatient care. It sets out clear expectations for providers to define and document clinical responsibility, implement structured handovers and escalation protocols, and ensure that every patient has a designated clinician or team responsible for their care at each stage of the outpatient journey.

The guide also promotes the use of improvement analytics and local insight to monitor outcomes, identify risks, and support continuous learning. These measures are designed to reduce the risk of fragmented care, missed follow-ups, and harm due to unclear ownership of care. For patients, this means greater transparency, improved communication, and safer, more coordinated treatment.

I hope this response addresses the concerns outlined in your report. Please do not hesitate to contact me should you require any further information.

Moorbridge School

10 Aug 2025 PDF

Action Taken

Moorbridge School has conducted a thorough review of their practices related to information sharing and safeguarding and will revisit and reinforce staff understanding of these policies through annual refresher training. (AI summary)

View full response

Dear Mr Hetherington, I write on behalf of Moorbridge School in response to your Regulation 28 report dated 23 June 2025 concerning the tragic death of . Firstly, please accept our heartfelt condolences to the family of the deceased. We recognise the profound loss and extend our deepest sympathies to all affected. Regarding your concerns outlined in section 5 of your report about the passage of information and communication, I wish to confirm that Moorbridge School takes safeguarding and information sharing with the utmost seriousness. In light of the issues raised, we have conducted a thorough review of our practices related to information sharing, safeguarding policies, and procedures. As part of our annual safeguarding refresher and other relevant training throughout the academic year , all staff have and will revisit and reinforce their understanding of these policies, with particular emphasis on timely and appropriate communication with relevant bodies and agencies. This training ensures that all members of our staff remain vigilant and proactive in sharing pertinent information to safeguard the welfare of all pupils. Moorbridge prides itself on fostering a culture of openness and collaboration with partner agencies, parents, and professionals to ensure the safety and wellbeing of every pupil. We are committed to

Headteacher - Deputy Head

continuous improvement and will continue to monitor and enhance our procedures to prevent any recurrence of communication lapses. We trust this response assures you of our commitment to safeguarding and effective information sharing.

49 Marine Avenue Surgery

13 Aug 2025 PDF

Action Planned

49 Marine Avenue GP Surgery acknowledges shortcomings and will strengthen communication with secondary care, improve multidisciplinary communication, and review safeguarding procedures. They will also implement new guidelines for monitoring, supporting families, and provide staff training in eating disorder management. (AI summary)

View full response

Dear Sir, We acknowledge receipt of the Regulation 28 report concerning the tragic death of and extend our sincere condolences to her family. We take this matter very seriously and appreciate the opportunity to reflect on the concerns raised and to outline our learning and planned actions to improve care delivery. Summary of GP Surgery Involvement:
1. Monitoring of Weight and Physical Health: We recognise that from November 2023 there was inadequate face-to-face monitoring of weight. As a GP surgery, we rely on multidisciplinary collaboration and clear communication to monitor complex cases. We invited for a face-to-face consultation, including weighing, by phoning and then texting directly to her mother; however, /her family did not contact us to attend for a weight appointment. We regret that despite these efforts we were unable to engage her directly.
2. Referral to Gastroenterology: We acknowledge the confusion around referral pathways between consultant services and use of the term "consider referral" and that the requested referral did not occur. We recognise this represents a critical missed opportunity to escalate care. Going forward, we will ensure clearer understanding of referral pathways and strengthen communication with secondary care colleagues to prevent similar delays.
3. Communication and Information Sharing: The report highlights concerns regarding the flow of information from other agencies, including the school and mental health services. We concur that a more robust system for sharing relevant clinical and safeguarding information is essential. We are committed to improving multidisciplinary communication, including liaising more proactively with schools, mental health services, and social care teams involved with patients at risk. Learning and Actions to be Taken: Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• Enhanced Face-to-Face Contact: The GP surgery already runs a primarily face- to-face appointment system, but we have reminded the team of the importance of this means of access, particularly where weight loss or malnutrition is a concern, to ensure accurate physical assessments. We will continue to reiterate the importance of face to face contacts at our monthly meetings and when any changes to appointment ledgers are considered.
• Clarification of Referral Pathways: We are fully committed in working with our secondary care colleagues to ensure that any information that is shared between primary and secondary healthcare pathways and communication is implemented as part of the learning and actions from this case. This will be discussed, for action, at the North East and North Cumbria GP Provider interface group by October
2025. If new pathways are introduced, we will seek to confirm they are operational rather than assume everyone is aware. If there is any uncertainty or ambiguity regarding the request in a letter, we will write back to the Consultant to clarify. If any actions are unable to be carried out for any reason, we will write to the Consultant to inform them and ask if any further action on our part is needed. We are reviewing internal processes to clarify responsibilities and improve timely referrals for specialist input.
• Improved Multidisciplinary Communication: We are developing strategies for better information sharing among primary care, secondary care, schools, and mental health services and have met with Northumbria Healthcare Foundation Trust regarding this. Specifically, we are looking into setting up monthly Multidisciplinary Team Meetings (MDTs), to enable sharing of information and timely interventions.
• New Processes and Policies: We have developed an Eating Disorders Management Standard Operating Procedure (SOP) and a Safe Management of Under-18s with Eating Disorders Policy. These cover the management of patients presenting with weight loss (attached). An initial audit has been undertaken to review all under-18s who have an eating disorder at 49 Marine Avenue Surgery and ensured our management is compliant with the new SOP and policy and that we have a robust review and recall system in place.
• Training and Awareness: We will provide staff training on the Medical Emergencies in Eating Disorders (MEED) guidelines to increase awareness of clinical red flags and escalation pathways. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• Patient Engagement: We acknowledge the challenges in engaging adolescents reluctant to attend appointments. We will review our approach to invite and follow- ups, considering additional support methods, including involvement of family and community services, to improve attendance and monitoring. We have recently reviewed our Safeguarding Policy (March 2025) which includes an Appendix on "Child Not Brought". This includes several safeguards to check a child is brought to an appointment/monitoring and checklists to re-engage and flag concerns if this is ongoing. The policy has been shared with the team. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services 49 Marine Ave Surgery, as part of Northumbria Primary Care (NPC) SOP: Management of Patients Under 18 with Eating Disorders Author: (Medical Director NPC) Date: 01/08/2025
1. Scope and Purpose This SOP applies to all general practice staff providing initial assessment and ongoing care for patients under 18 presenting with suspected or diagnosed eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, OSFED).
2. Overarching Principles
• Management is multidisciplinary and family-inclusive, with early referral to specialist community-based eating disorder teams when indicated.
• Safeguarding, capacity/consent, and physical health monitoring are core, non- delegable responsibilities.
3. Recognition, Screening, and Initial Assessment
• Be alert to eating disorders in young people with low BMI, unexplained weight loss, growth faltering, amenorrhea, repeated vomiting, Gl symptoms, psychosocial distress around food/weight, or mental health concerns.
• Ask screening questions directly: e.g., “Do you think you have an eating problem?” and “Do you worry excessively about your weight?”
• If a gastrointestinal cause for the weight loss is suspected, early referral to secondary care, gastrointestinal services should be considered at the outset or at any other time in the management of the patient if their condition changes and suggests a gastrointestinal problem. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services Initial assessment must include:
• Physical health: weight, height, BMI centile, pulse, BP (lying/standing), temperature, signs of dehydration or medical instability (refer to MEED: Medical Emergencies in Eating Disorders guidance).
• Mental health: risk of self-harm or suicidality, psychological distress, depression, anxiety.
• Social/family context: eating patterns, exercise, impact on education/social function.
• Safeguarding: assess risk of abuse/neglect in every case, document and escalate concerns per local protocol.
4. Immediate Risk Assessment
• Immediate hospital admission is required for any child or young person with features of acute physical risk (marked bradycardia, hypotension, hypothermia, syncope, electrolyte disturbance, severely low BMI centile for age, rapid weight loss, or evidence of systemic compromise).
• Severely low BMI in children/adolescents is typically: BMI for age below the O.4th centile (or less than the 5th centile if no contextual factors are given), or BMI below 70-75% of the median for age/sex and must be interpreted in conjunction with clinical factors and physical health status
• Refer urgently to specialist eating disorder services if eating disorder is suspected and there is significant impairment or risk.
5. Safeguarding, Consent, and Confidentiality
• Involve children/young people and their families in all decisions, unless harmful or not in best interests. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• Assess and document Gillick competence (under 16): seek valid consent or parental involvement as appropriate. For 16-17s, assume capacity unless evidence to the contrary.
• Respect confidentiality but explain exceptions (risk to self/others). Record legal authority for decisions, especially in contested or overridden treatment.
6. Ongoing Care and Referral
• Every patient should have a care plan for ongoing physical and psychological monitoring, coordination with specialist services, and emergency action.
• Growth and physical health (weight, height, vital signs) should be monitored frequently per specialist or local protocol—seek paediatrician input for faltering growth or medical instability.
• Psychological/medical comorbidities (e.g., diabetes, depression): coordinate MDT management and review regularly.
• People referred to specialist services should begin assessment and treatment within 4 weeks (for children and young people), in line with NHS Access and Waiting Time Standards.
7. Family and Psychoeducation
• Family interventions are first-line: offer evidence-based family therapy (such as anorexia-focused family-based therapy, 32 40 sessions over 12-18 months with additional sessions for parents/carers).
• Provide or refer for psychoeducation to patient and family about risks, nutrition, relapse prevention, impacts on mood, social function, body image, and safety.
8. Referral Pathways and Escalation
• Refer all suspected cases to local community-based eating disorder teams (children/young people) without delay. Follow the NHS England Access and Waiting Time Standard targets.
• In urgent risk, refer to paediatric inpatient care with facilities for specialist refeeding and monitoring—use age-appropriate settings. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• If treatment is refused but deemed essential, follow legal pathways (Mental Health Act, Children Act; seek senior and legal advice).
9. Medicines Management
• Medication is never sole therapy for eating disorders in under-18s; it may be used as adjunctive treatment only under specialist guidance.
• Review all current prescriptions for potential health risks (QT prolongation, risk of dehydration, etc).
10. Documentation
• Record all assessments (including physical and psychological risk), consent discussions, safeguarding steps, referrals, and communications contemporaneously using appropriate coding (e.g., “vulnerable child”, “child protection”).
11. Audit and Quality Assurance
• Review all cases regularly at practice MDT meetings and audit care against NICE NG69 and MEED standards.
• Seek regular updates and training for all staff in safeguarding and eating disorder recognition/management. Key References NICE NG69: Eating Disorders—Recognition and Treatment MEED (Medical Emergencies in Eating Disorders) guidance Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services Policy for the Safe Management of Under 18s with Eating Disorders August 2025 Operational Summary This policy provides a comprehensive, standardised framework for the identification, assessment, referral, and ongoing management of patients under 18 presenting with eating disorders. It includes the use of SystmOne with embedded Ardens Templates, specifies safeguarding responsibilities, and sets out coordinated working with local partners including CNTW, CYPS, Northumberland Foundation Trust, and Newcastle Foundation Trust, in line with current legal and clinical guidance.
1. Introduction Eating disorders in children and young people are serious mental health conditions associated with significant physical and psychological morbidity. General practice teams have a vital role in early recognition, risk assessment, physical monitoring, safeguarding, and coordination of care with specialist services and multi-agency partners.
2. Purpose To ensure the prompt, safe, and evidence-based management of under 18s with suspected or diagnosed eating disorders. To comply with regulatory requirements and NICE NG69 guidance. To detail processes for safeguarding, assessment, risk stratification, referral, monitoring, and liaison with families and external agencies.
3. Duties All Staff: Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• Identify possible eating disorder presentations.
• Escalate concerns and follow safeguarding pathways.
• Document assessments and actions fully using SystmOne/Ardens Templates. GPs/Clinical Leads:
• Undertake full risk/medical assessments.
• Coordinate referrals and ongoing communication with specialist services and safeguarding teams.
• Oversee quality assurance and compliance audits. Site Lead:
• Ensure staff training and operational resources to assess health status.
• Support audit and version control.
4. Definitions
• Eating Disorder: Anorexia nervosa, bulimia nervosa, binge eating disorder, or avoidant/restrictive food intake disorder as defined by DSM-5/NICE NG69. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• Safeguarding: Processes to protect young people from neglect, abuse, exploitation, as mandated in the Children Act 1989/2004 and Working Together to Safeguard Children (2018).
• CNTW/Northumberland FT/Newcastle FT/CYPS/CAMHS: NHS and local authority specialist services for children and young people’s mental health and safeguarding.
• SystmOne/Ardens Templates: Electronic clinical templates for recording and standardising history, risk, safeguarding, and referrals in general practice.
5. Process
5.1 Recognition and Initial Assessment
• Identify at-risk patients through history, examination, growth monitoring, and parental/third party concerns.
• Use the Ardens Eating Disorder Template in SystmOne for a structured assessment, including:
• Eating and weight-loss patterns
• Growth chart centiles (WHO/RCPCH standards)
• Physical risk factors (as per MEED “traffic light” tool)
• Mental health and self-harm screening Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• If a gastrointestinal cause for the weight loss is suspected, early referral to secondary care, gastrointestinal services should be considered at the outset or at any other time in the management of the patient if their condition changes and suggests a gastrointestinal problem.
5.2 Safeguarding Assessment
• Assess all presentations for potential safeguarding concerns.
• Document and act on issues through the SystmOne Safeguarding Ardens Template.
• Refer immediately to local authority safeguarding or CYPS when indicated, following ‘Working Together to Safeguard Children’
5.3 Risk Stratification and Referral
• High-risk presentations (marked weight loss, bradycardia, electrolyte disturbance) require urgent referral to Paediatrics
• For less acute cases, refer for specialist assessment local CYPS / CAMHS Eating Disorders service (CNTW, Northumberland FT, as per locality) via usual local protocols.
5.4 Multi-Agency Working
• Engage with all multi-disciplinary teams including mental health, paediatrics, school health, social care and safeguarding teams. Attend meetings in person if possible. If not deputise and if no-one can attend, ensure that a report is provided to fully inform the meeting about activity in Primary Care. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
• All contacts, actions and referrals are to be recorded using communication and referral templates in SystmOne.
5.5 Ongoing Monitoring and Follow-Up At regular intervals, repeat full risk/physical health assessments should be undertaken in line with NICE guidance. The frequency should be individualized based on risk but generally at least every 1-2 weeks initially, and as often as clinically indicated during weight restoration or if there is any acute risk. Where and by whom this is taking place should be agreed by all agencies, fully documented in the care records and outcomes shared at multidisciplinary team meeting. For mild to moderate severity (medically stable, no acute risk):
• Physical health monitoring includes:
• Regular weight and height checks
• Pulse, blood pressure (lying and standing), and temperature
• Assessment for physical signs of malnutrition or dehydration
• Blood tests (as indicated for electrolyte imbalance, renal/liver function)
• Frequency: At least every 1-2 weeks initially, with interval extended if stable. High Severity / Increased Physical Risk (rapid weight loss, acute symptoms, or physical instability): Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services Monitor more frequently:
• Vital signs (pulse, blood pressure, temperature) often several times a week or daily if needed
• Daily or more frequent weight monitoring where medically indicated (especially inpatient)
• Electrolyte and other relevant blood testing at least weekly or more often as indicated
• ECG monitoring if at risk of cardiac complications (e.g., bradycardia, QTc prolongation) or when taking medications that may affect cardiac function
• Monitor for signs such as fainting, cardiac arrhythmias, or new physical symptoms. Very High Risk (Medical Crisis/Emergency): May require continuous inpatient monitoring (e.g., cardiac monitoring), urgent correction of abnormalities, and intensive physical review ongoing as dictated by their status.
• Weight, height, BMI centile, BP, pulse, relevant blood tests
• Mental health, risk of self-harm/suicide Document in SystmOne using the Ardens Templates and growth chart tools. Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services
5.6 Supporting Families and Providing Information
• Offer information on both local and national support resources (self-help, family support, parent groups).
• Liaise as needed with school nursing and community teams to support education and ongoing care.
5.7 Training and Quality Assurance
• Ensure all staff access regular training in eating disorder management, safeguarding, and the use of SystmOne/Ardens templates.
• Audit practice compliance with this policy annually, reporting findings to the practice leadership team.
6. References NICE NG69 Eating Disorders: Recognition and Treatment (2017) Children Act 1989, 2004 Working Together to Safeguard Children (2018) CQC Regulation 12: Safe Care and Treatment Royal College of Psychiatrists: Medical Emergencies in Eating Disorders (MEED) Guidance (2022) Part of Northumbria PRIMARY CARE

NHS NPC 49 Marine Avenue Providing NHS services Part of Northumbria PRIMARY CARE

Northumbria Healthcare NHS Foundation Trust NHS / Health Body

15 Aug 2025 PDF

Action Taken

The Trust has implemented a restructure within the Dietetics Service, introduced mandatory training for staff on safeguarding children, and will discuss information sharing between primary and secondary healthcare at the NENC GP Provider interface group by October 2025. (AI summary)

View full response

Dear Mr Hetherington

REPORT TO PREVENT FUTURE DEATHS – INQUEST TOUCHING THE DEATH OF

I am writing to you in response to the Report to Prevent Future Deaths (PFD) served on Northumbria Healthcare NHS Foundation Trust ("the Trust") on 23 June 2025, following the inquest into the death of .

Your report was also sent to the 49 Marine Avenue GP Practice, Moorbridge School, Department of Health and the Northeast and North Cumbria Integrated Care Board (ICB). I am writing to provide you with the Trust response to your concerns. For ease of reference, I have addressed each concern using the same numbering as referred to in the PFD Report.

Concern 1: The Deceased's weight and height was not adequately monitored from November 2023.

1. During the course of the inquest, in written and/oral evidence, the Trust confirmed that the following actions had been completed to address this learning point:

2. Internal management re-structure within Dietetics Service to introduce, and empower, a Community Team Lead to oversee and manage all the outpatient work from triage and clinic capacity to reporting, monitoring and planning. This facilitates the provision of alternative outpatient offers, including home visits where concern is raised regarding

outpatient in-person attendance for any high risk, vulnerable patients. It allows improved oversight of staffing in terms of mobilisation of resource, training and support regarding escalation pathways and case reviews. This change in structure was implemented in February 2025.

3. Introduction of SystmOne as a clinical electronic records system for Nutrition and Dietetics outpatient consultations (Go Live of the Nutrition and Dietetics SystmOne unit was August
2024) provides:

3.1 Improved transparency and visibility of consultations with community partners including the GP.
3.2 Improved, instant, communication with the GP via the system (less reliant on written letters to pass information).
3.3 Improved visibility and tracking of patient weights, heights and clinical investigations.
3.4 Improved, auditable, triage process via the SystmOne clinical system, including robust assessment, by senior Dietetic staff, of the information provided and appropriate direction/clinic allocation.

4. Introduction of robust, documented clinical supervision was launched formally at the Nutrition and Dietetics Department meeting on 1 April 2025, within the Dietetics staffing structure and also with the Nutrition Team MDT from July 2025.

4.1 Dietitians are now supported to critically review patients with very low Body Mass Index’s (BMIs) to consider escalation to the Nutrition Team MDT and MEED Oversight Group.
4.2 Ongoing support is offered to staff in a variety of settings including routine monthly 1:1s, timetabled clinical supervision sessions, monthly team meetings and thrice weekly virtual huddles and this was in place prior to the death of .

5. Development of a Nutrition Multi-disciplinary Team (MDT) meeting which includes medical oversight from Gastroenterologists for complex and vulnerable Dietetic outpatients and mental health oversight from colleagues from the mental health Trust. The first meeting took place on 15 July 2025, scheduled to meet fortnightly and is on track with scheduling. The initial meetings were held with Dietetics and the Trust Gastroenterology consultants to review the current caseloads. Concerns may also be raised to this group outwith the scheduled meetings. This MDT will include mental health colleagues from going forward. The terms of reference are currently being established and will be in place for joint meetings to be scheduled from September 2025.

6. Implementation of the Medical Emergencies in Eating Disorders (MEED) Oversight Group; this group has been meeting every 6 weeks since August 2024. This Group includes colleagues from the mental health Trust to monitor and review policies, processes and high-risk patient pathways and includes Executive Director oversight from both Trusts. The function of the Oversight Group is to agree and formalise operational policies and processes rather than for clinical discussions. However, it has provided opportunity for discussing specific, existing, cases whilst the joint clinical MDT is established.

7. The below actions, which had been identified before the Inquest, but were not yet complete, have since been progressed and put in place:

8. A Standard Operating Procedure has been developed and introduced from July 2025 for triage and management of suspected Eating Disorders/ Disordered Eating referrals at triage and assessment.

9. From August 2025, face to face appointments are now routinely offered by the Dietetics service as first contact for any patient referred for nutritional support and weight loss (irrespective of the cause). If telephone contact is required for timeliness, then an in- person review appointment will then be offered after the initial telephone assessment.

10. Nutrition and Dietetics staff working with patients from 16 years and above, have been advised by the Professional lead for Dietetics, at the monthly Adult team meeting on 25 June 2025, to consider the national MEED guidelines and ARFID (Avoidant/Restrictive Food Intake Disorder) checklist to support the assessment of patients in the out-patient setting for current and future caseloads:

10.1 MEED assessment tool link has now been embedded in the outpatient consultation record.
10.2 Improved clinical awareness for any patient with a low BMI to be assessed for risk factors, irrespective of potential reason.
10.3 Training is to be delivered to the Nutrition and Dietetics team CNTW dietetic colleagues, to support identification and management of eating disorders/disordered eating. There are a series of bookable webinars arranged for staff: 18 September 2025; 15 January 2026; 23 April 2026 and 16 July 2026. In addition, a colleague from the mental health Trust will be attending the Nutrition and Dietetics department meeting on 15 October 2025 to give an update and training to all staff in the department. A register will be taken, and the training resources will be supplied to any front-line staff member not in attendance. The Adult Dietetics team meeting on 26 August 2025, has been specifically allocated for mental health training. Feedback from a Trust-wide session on managing mental health in non-mental health settings and feedback on British Dietetic Association (BDA) eating disorders training will be shared at this meeting.

11. Internal communications and safety messages have been cascaded to Trust staff regarding the importance of obtaining accurate height and weight measurements in July 2025, including frequency of assessment and clarity on how the measurements were obtained, documented within the approved Trust-wide Nutrition and Hydration Policy.

12. The Trust are continuing to review all clinical systems and digital platforms to streamline, where possible, the reporting of weight and height and the interoperability of systems to provide assurance that measures are captured and reported centrally by all services.

13. Since the conclusion of the inquest, the Trust have further looked at systems and processes in place and identified the additional actions, below, which remain ongoing:

14. Introduction of a Standard Operating Procedure (SOP) for management of patients referred to the Nutrition and Dietetics department that do not attend (DNAs) or are not brought to appointments. The SOP will be in line with Trust’s framework for non- attendance and the Outpatient Steering Group recommendations. Referrals for patients with a very low weight and BMI who do not attend appointments require further discussion to agree acceptable tolerances Trust-wide. This action will be raised via the Outpatient Steering Group for consideration at the September 2025 meeting.

15. Improve process and management of transition of patients (16-18 years) within the Nutrition and Dietetics service:

15.1 Ensure patients are not ‘lost’ between paediatric and adult services.
15.2 Age-appropriate assessments are used.
15.3 Consider ‘transition clinic’ for adolescents and young adults.

This is ongoing work within the Dietetics leadership team to be finalised by the end of 2025 and will be led by the Adult and Paediatric Dietetic team leads.

16. Mental Capacity Act (MCA) Training for all Nutrition and Dietetic staff was delivered during February and March 2025 by the Trust MCA Lead from the Safeguarding department. The intention of the training was to equip staff with the skills and knowledge to assess whether a patient had capacity to make decisions about their care and provided support to escalate concerns regarding any patients who may not have capacity. The confidence to make assessments regarding mental capacity should support staff to navigate the appropriate escalation pathway for vulnerable, high-risk patients.

17. Introduction of regular, safeguarding supervision for the team from April 2025 to support safeguarding decision-making has been implemented; the second session will be in September 2025 and then twice yearly on a rolling basis.

Concern 2: There was no referral to Gastroenterology.

18. The Falls & Syncope outpatient clinic contact letter, dated 20 November 2023, requested that the GP monitored for weight loss and referred into the Trust Gastroenterology specialty for further assessment. His Majesty's Coroner was concerned that this referral was not made by the GP, or directly by the referring Consultant in the Falls & Syncope team.

19. During the inquest, the Trust gave oral evidence regarding the implementation and cascading of the new consultant to consultant referral guidance. The Trust has adopted the Northeast North Cumbria (NENC) Consultant team to Consultant team referral policy via the Northumberland and North Tyneside GP/Provider interface group organised via NENC ICB. This will be adopted as a local policy and communicated to all clinicians within Northumbria by the Trust Policy group on behalf of the Executive Medical Director by the end of October 2025, following consultation/ratification at the Trust’s CPG (Clinical Policy Group). Primary Care colleagues also have access to the Trust’s Advice and Guidance service across the acute secondary care specialties to request advice and guidance on clinical cases, in this case including Gastroenterology.

20. The Trust allows inter-specialty referrals and also referrals ‘to’ and ‘from’ other provider NHS Trust’s where there is an appropriate repatriation and transfer of care required.

21. The Trust’s newly established Nutrition MDT would also consider and offer where more bespoke and specialist clinical nutrition advice and support is required for other specialties.

Concern 3: The Deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed.

22. After referral to CAMHS on 20 November 2023, an appointment was arranged for on 13 December 2023. This appointment was cancelled by the family, but CAMHS made further contact via telephone with the family to establish if they had any concerns. CAMHS were told did not want to attend, so no further appointments were made.

23. During the Trust's investigation and the inquest process, the CAMHS team did review their involvement with , and made the following changes to their systems and processes. The evidence given in writing and at the inquest on these matters can be summarised as follows:

24. In January 2025, the 'Was Not Brought/Did Not Engage' CAMHs guidance was updated to include frequent cancellation guidance. This encompasses non-engagement of young people and children. In this situation, cases will be discussed within the CAMHS MDT and if deemed appropriate, escalated for consideration of a safeguarding referral or Early Help assessment (Early Help is explained in more detail below, in paragraph 31). The addition, the CAMHS guidance outlines that if concerns regarding weight loss and/or restricted dietary intake are identified in the referral and child or young person was not brought or fails to engage in appointments, safeguarding advice and referral must be considered.

25. Prior to a decision being made relating to discharge if a child or young person will not attend for a CAMHS assessment, a discussion within the CAMHS MDT will take place and every effort made to discuss with the referring clinician. Clarification will be undertaken at the MDT case discussion with regard to dates when height and weight measurements were taken, and by who, to support the decision-making process. These discussions focus on the potential risks and wider factors impacting on the health and wellbeing of the young person, including consideration as to whether a physical assessment has been completed or is needed.

26. Following the inquest, the CAMHS team have taken the below, additional actions to further address the Coroner's concern:

26.1 An initial awareness raising training session has been delivered to 41 CAMHS Staff, on 15 July 2025, with a focus on assessment and risks of low weight and associated health needs. Further training is scheduled on 18 September 2025.
26.2 Efforts are made to capture the voice of the child/ young person via phone contact and offer of appointment. This is undertaken for each assessment and forms part of the information gathering when a parent or carer is the primary contact. The non- engagement guideline would be applicable in this instance. The non-engagement guidance outlines If a young person, parent or carer cancels an appointment and it is re-booked, care coordinators/Key workers will assess any patterns and the potential risks. They will re-assess the plan of care as needed and inform relevant others depending on the level of concern.
26.3 'Was Not Brought' and cancellation rates will be reviewed through caseload management (CLM) meetings with clinicians. The purpose is to review caseload numbers, was not brought and cancellation rates. Checks are also made that risk assessments and care plans have been completed. Frequency of caseload management depends on the role of staff e.g. Consultant Psychiatrists have CLM every 3 months. Other members of staff may have CLM every 2 months. This provides assurance that governance processes are being followed.

Concern 4: There was no in-person assessment by Dietetics, or escalation of care.

27. The Dietetics service aims to return to a pre-COVID out-patient position whereby face-to- face appointments are offered as standard for all appointments. However, this is likely to require additional resource and a commissioning review. In the meantime, face to face appointments will be prioritised to all younger persons with red flags for low BMI.

28. The ability to track and report outpatient activity has been implemented via the SystmOne reporting mechanism to support future discussion. Home visits were previously only offered for frail, elderly, housebound patients as a result of commissioning arrangements and issues with demand for the service significantly outweighing capacity. Whilst the commissioning and resource challenges remain, new management oversight of all Dietetic clinics has enabled greater mobilisation of the staffing resource from all areas within the Adult Dietetic service, optimising outpatient capacity and increasing flexibility of the offer.

29. The standard referral criteria to the Dietetics service for nutrition support is patients with a BMI of less than 18.5 and/or 5-10% weight loss within 3-6 months. Higher risk patients (i.e. those referred with a BMI of less than 17.5, in line with MEED definitions for immediate risk to life) can now be offered a home visit, if it is felt that the patient won’t or can’t attend an in-person appointment at one of the Trust sites.

30. All higher risk patients will be offered a face-to-face appointment going forward and if a telephone contact is required to facilitate a timely intervention it will be followed by an in- person appointment to ensure accurate weight and height is recorded. Face-to-face appointments for all patients who are not triaged as ‘higher risk’ are offered where possible and would be based on individual clinical need and may require further commissioning discussions.

31. The service is working on a SOP which will provide further assurance that patients are appropriately managed by the Dietetics Admin team. This SOP will include pathways to manage patient DNA’s, cancellations and patient/carer requests to change to a telephone call instead of an in-person contact, or to be discharged without further review. The Admin team will be able to task the clinicians via SystmOne with requests by patients to change appointments and clinicians will need to review the patient record to confirm and agree in writing that the changes are acceptable. This SOP will be cascaded and implemented following the Department meeting in October 2025.

32. The Trust acknowledges (e.g. because of patient choice) that it is not always possible to guarantee all first appointments are face-to-face, but that, all first attendance appointments should be face-to-face where clinically appropriate, and this standard has been set at the Outpatient Steering Group.

Concern 5: The passage of information/communication.

33. In North Tyneside there is a Multi-Agency Safeguarding Hub (MASH) which was launched in 2017 (the Local Authority is the Lead Agency) and is the single point of contact to access services for children and young people and also the contact point where information can be shared where there are identified concerns or worries from partner agencies. The Trust's Safeguarding Department are fully integrated into the MASH as well as other key agencies such as Children's Services, Police, mental health services, Education, Primary Care and 0-19 school health.

34. The Community Paediatrician from the Trust was contacted by the Early Help Service in December 2022 about their views on ending the involvement of Early Help with

and her family. The Trust Paediatrician opined that it was important for this to continue as it was beneficial for the whole family, as did school, as it meant that there was coordination between all of the agencies involved and school still had concerns at that time in relation to . The Early Help Service in North Tyneside Local Authority felt that the only issue outstanding was around Education and subsequently closed the Early Help/Family Partner involvement in April 2023.

35. If any Trust staff member or clinician has any safeguarding concerns or are worried about children or young people in their care, the first point of contact would be by seeking advice and support from the Trust's Safeguarding service or raising a safeguarding referral to the Local Authority, which would go via the MASH. Alternatively, they can also raise their concerns directly with the Local Authority and during out of hours.

36. The Trust would then fully engage within any subsequent MASH records checks and any meetings which are coordinated via the Local Authority MASH as part of the inquiry

process. This then allows all agencies to look at all information together, which may inform a wider picture of any concerns and risks and to form a plan. This forms a Signs of Safety Model to ensure child safety and wellbeing and involves a structured approach to assessment and planning to create safety for a child. The model does rely on each agency reporting concerns into the MASH.

37. Since the Coroner’s Inquest and receipt of the Regulation 28 report, the Trust have had further discussions with the ICB, and this case is being taken forward for further scrutiny and learning via the North Tyneside Safeguarding Partnership.

38. We are fully committed in working with our GP colleagues to ensure that any information that is shared between primary and secondary healthcare pathways and communication is implemented as part of the learning and actions from this case. This will be discussed, for action, at the NENC GP Provider interface group by October 2025.

As a Trust, the safety and wellbeing of those we provide service to is paramount, and despite the unfortunate circumstances in which your concerns have arisen, we welcome the opportunity His Majesty's Coroner has provided for us to further address the above issues. We also look forward to the responses from the Department of Health and the ICB.

Department for Health and Social Care Central Government

19 Dec 2025 PDF

Action Planned

The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue and aim to have a Single Patient Record processing information by 2028. (AI summary)

View full response

Dear Mr Hetherington,

Thank you for the Regulation 28 report of 23 June 2025 sent to the Department of Health and Social Care about the death of . I am replying as the Minister with responsibility for data and technology.

Firstly, I would like to say how saddened I was to read of the circumstances of death, and I offer my sincere condolences to the family and those who loved her. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter.

The report raises concerns relevant to the Department of Health and Social Care over there not being a single accessible system for weights, height and BMI, and a lack of clarity regarding oversight of care in an outpatient setting.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.

There are two BMI tools; one designed for use with adults aged 18 and over and the other for children and young people 17 and below.

NHS England has prepared within its NHS.UK guidance, advice for parents and families on this topic (https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass- index/calculate-bmi-for-children-teenagers) which states it should not be used if they have

an eating disorder and gives further advice for those who have (https://www.nhs.uk/mental- health/feelings-symptoms-behaviours/behaviours/eating-disorders/advice-for-parents/).

The plotting of height and weight for children commences at birth and results are entered into the parent held 'Red Book' and plotted on a centile chart which is intended to stay with the child throughout their lifetime. The digital Healthy Child Programme intended to digitise the 'Red book' commenced in 2019 with the goal of ensuring information could be shared more easily with parent and professionals alike. However, due to the extreme demands of COVID on the digital programmes and necessary reprioritisation, the digitisation of the Red Book was paused in 2021/22 but is again being discussed in NHS England in light of both the Single Patient Record (SPR) developments, described below, and incorporating newer technologies.

Currently the Summary Care Record (SCR) contains a summary of a patient’s health information recorded on their GP record. This includes sharing information such as allergies, adverse reactions and medications for all patients - except where patients have opt-out – and for approximately 89% of the population also includes additional information relating to their medical, surgical and psychological history. The SCR is available to health and care professionals. Patients can access similar information about themselves via the NHS App along with all medical consultations.

Secondary Care Providers can upload care plans and other clinical documents to the National Record Locator (NRL) developed and maintained by NHSE. The NRL is expected to integrate with local shared care records services and other suppliers which will result in broader and more consistent access for all health care providers.

It is recognised by NHS England that the joining up of records to achieve easy access to all the information by clinicians and 'patients/their guardians' remains a challenge and NHS England with the Department of Health and Social Care is currently executing a substantial programme of work to increase the interoperability and sharing of all patient records, including medical history, investigations and vital patient measurements (Blood pressure, Height and Weight etc) and would include centile charts in paediatric services. This has been outlined in the Governments 10 Year Plan and the ambition to develop a 'Single Patient Record.

I agree that ensuring health and care professionals have access to a single source of digital information about the patients they are treating and caring for is vitally important to delivering the best care possible. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue.

NHS England is currently executing a substantial programme of work to increase the interoperability and sharing of all patient records, including medical history, investigations and vital patient measurements (Blood pressure, Height and Weight etc). This has been outlined in the Government’s 10 Year Health Plan and the ambition to develop a single patient record.

The Government’s 10 Year Health Plan commits to the delivery of a SPR. This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place which will help prevent unfortunate incidents where fragmented and disjointed information prevents treatment from being provided on time.

Introducing a SPR will give clinicians all the data they need when treating patients. By having access to all relevant information about a patient, frontline staff will be able make more informed decisions and deliver the best care at the time it is needed. We are aiming for the record to begin processing information by 2028.

Thank you for bringing these concerns to my close attention.

Report sections

Investigation and inquest

I commenced an investigation into the death of REDACTED Deceased. The investigation concluded at the end of the inquest on 19 June 2025. The medical cause of death was confirmed as 1a Pulmonary aspiration of stomach contents 1b Gastroparesis 1c Extreme Malnutrition The conclusion of the inquest was a narrative conclusion: Died as a result of the effects of extreme malnourishment. Opportunities to recognise the weight loss and escalate care were missed after November 2023. It is not possible to say whether the outcome could have been prevented with earlier escalation.

Circumstances of the death

The deceased was aged 17 years of age. She had a diagnosis of Autistic Spectrum Disorder and suffered with anxiety. She complained of symptoms of brain fog, syncope, blurred vision and chronic fatigue which she attributed to COVID 19 or a physical cause. She experienced significant weight loss. She underwent a number of investigations including for an autonomic dysfunction (Postural Orthostatic Tachycardia syndrome) and no formal diagnosis was made. The investigations raised the suspicion of vasovagal response and deconditioning. She admitted to restricting her diet to manage her symptoms. The deceased was seen in the syncope clinic on 20 November 2023. Her weight was recorded as 42.9 kg with a BMI of 16.6. The Consultant Physician was concerned that the deceased was underweight and further investigation of her weight loss was appropriate. On 20 November 2023 referrals were sent to the General Practitioners, Child and Adolescent Mental Health Services and Dietetics to monitor her weight. By the time of her admission to hospital on 30 April 2024 her weight was 26.6 kg. I heard this was 50% of what would be expected as her median weight. From 20 November 2023 her weight had decreased by 16.3 kg. She was admitted to Northumbria Specialist Emergency Care Hospital from home on 30 April 2024 in an advanced state of starvation and with a very low Body Mass Index. The clinicians recognised the imminent risk to life. She agreed to nasogastric feeding and a nasogastric tube was placed on 2 May 2024. On 3 May 2024 she was placed under Section 2 of the Mental Health Act for assessment and treatment. On 5 May 2024 before insertion of a central venous line into the jugular she was placed head down, felt nauseous and went on to vomit. She was rolled over onto her left side and oropharyngeal suction was applied. There was a rapid decline in her condition, she became bradycardic and cardiac output was lost. Despite cardiopulmonary resuscitation she died within the critical care unit at Northumbria Specialist Emergency Care Hospital at 10.25 hours on 5 May 2024.

Copies sent to

Northumbria Healthcare NHS Foundation Trust49 Marine Avenue SurgeryMoorbridge SchoolNorth East and North Cumbria Integrated Care BoardDepartment of Health

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Shared signals

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Report details

Reference: 2025-0314
Date of report: 23 June 2025
Coroner: Andrew Hetherington
Coroner area: Northumberland

Responses identified

Responses identified 5 of 5

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Sep 2025 (estimated).

Sent to

49 Marine Avenue Surgery

Department of Health and Social Care

Moorbridge School

North East and North Cumbria Integrated Care Board

Northumbria Healthcare NHS Foundation Trust

Part of a series

10 reports

2019-0397 0 responses identified

2020-0061 All responses identified

2022-0036 1/2

2022-0095 0 responses identified

2023-0115 0 responses identified

2024-0031 All responses identified

2025-0045 All responses identified

2026-0245 All responses identified

None 1/2

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.