Source · Prevention of Future Deaths

Karen Graham

Ref: 2026-0384 Date: 31 Jul 2026 Coroner: Victoria Davies Area: Cheshire 1 response identified · 1 indexed addressee View PDF

Response deadline: 23 November 2026 (estimated from the Judiciary.uk publication date).

Date 31 Jul 2026

56-day deadline 23 Nov 2026 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 1

Coroner's concerns

Coroner’s Concerns (source excerpt)

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Lack of awareness of MEED guidelines amongst emergency department clinicians. It was the evidence of the Consultant in Emergency Medicine that he had not been aware of the MEED guidelines before they were sent to him by the court as part of preparation for the inquest. On discussion with his colleagues, they were also unaware of them. It was his evidence that, whilst the number of patients to whom they apply is very small, it would be very helpful to be aware of the existence of them for future patients. To that end, the team at Leighton Hospital have developed their own local guideline in accordance with the MEED guidelines, which is now available on the trust’s intranet.

This is then much more accessible and likely to be found by someone with, no knowledge of their existence, is essentially checking if there is a relevant guideline, than if it was not on the intranet.

I am concerned that this lack of awareness prior to the inquest is not an issue exclusive to Leighton Hospital. I am aware of a Report to Prevent Future Deaths from December 2021 in the inquest of Nichola Lomax where this was raised as an issue (albeit the guidance at that time was ‘MARISPAN’) and a report was written to various national organisations, although not the Royal College of Emergency Medicine at that time. A similar issue was raised in a Report to Prevent Future Deaths at the inquest touching the death of Averil Hart in March 2021. The response to the report from November 2021 from the Royal College of Psychiatrists details actions which were being taken to raise awareness. I am concerned that these actions have not been effective, given the lack of knowledge at Leighton Hospital, and that the organisation who are most appropriate to consider this further is the Royal College of Emergency Medicine.

Responses

1 respondent

The Royal College of Emergency Medicine

Education

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AI-classified response stance Action Taken

AI-generated response summary

The Royal College of Emergency Medicine has produced and published a new 'Eating Disorders Red Flags Safety Flash' to improve awareness of MEED guidelines among ED clinicians. They also plan to consider mental capacity issues related to severe eating disorders during an update to their Mental Capacity guidance next year.

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Dear Ms Davies, Further to your Regulation 28 Report following the conclusion of your inquest into the death of Karen Jayne Graham, the Royal College of Emergency Medicine (RCEM) would like to extend its sincere condolences to Ms Graham's family and friends. RCEM notes your concern regarding a lack of awareness amongst Emergency Department clinicians of the Medical Emergencies in Eating Disorders (MEED) guidance. RCEM welcomes the recommendations in this report. We recognise that people suffering with severe eating disorders are both at high risk of harm and are complex patients to help. For many years RCEM ran an annual day-long training event on eating disorders in the Emergency Department. We were also involved in the revision of MARSIPAN to MEED and have produced a Safety Flash on Anorexia Nervosa. RCEM Learning, our online education platform, has published educational content on eating disorders, including material following publication of the updated MEED guidance. We were saddened to hear that Emergency Medicine staff were not aware of the existence of the MEED guidance. RCEM has therefore produced a further Safety Flash which provides a concise summary of key red flags, common pitfalls, and key actions for Emergency Department clinicians, while specifically highlighting the role of the MEED guidance in the assessment and management of patients with eating disorders. The Safety Flash is available here: Eating Disorders Red Flags Safety Flash. RCEM is also due to update its Mental Capacity guidance next year and will consider covering the mental capacity issues associated with patients suffering from severe eating disorders during that review. This is clearly a topic which requires continued focus, and RCEM remains committed to supporting Emergency Department clinicians through education and patient safety initiatives.

[Page 2] With kind regards, RCEM Quality in Emergency Care Committee Co-Chair

Report sections

Investigation and inquest

On 21 January 2026 I commenced an investigation into the death of Karen Jayne Graham aged 54. The investigation concluded at the end of the inquest on 31 July 2026. The medical cause of death was 1a anorexia nervosa. The conclusion of the inquest was that Karen died from natural causes. There were no causative failings in care identified for Karen.

Circumstances of the death

Karen Graham had a longstanding history of anorexia nervosa, for which she was under the care of the eating disorder team for many years. Her BMI was chronically low and would fluctuate regularly. On 15 January 2026 it was identified that Karen had lost a significant amount of weight since last being weighed on 6 January, although reported no physical health symptoms. A plan was in place for follow up, review and consideration of admission to an eating disorder unit on 19 January. Sadly, Karen was found deceased in bed at her home on 17 January 2026.

On 6 November 2025 Karen attended Leighton Hospital feeling weak. She was assessed and, aside from low BP and low BMI, both of which were either long standing or normal for her, no concerning signs were noted.

An ECG was undertaken to look for rhythm abnormalities which can occur with poor nutrition and electrolyte disturbances, but this was normal.

Karen was discharged. There was no discussion with the mental health team, as Karen refused, and Karen was not weighed.

At the time, the team in the emergency department were unaware of the existence of guidelines to support doctors in acute settings in managing patients with eating disorders – Medical Emergencies in Eating Disorders: guidance on recognition and management-I will refer to them as the MEED guidelines. Had they been aware, I found it likely that Karen would have been weighed, or at least been asked if she could be weighed, and a discussion had with the liaison psychiatry team to see whether any further action was required. This would have led to a conversation with her consultant psychiatrist in the eating disorder team. For various reasons, I found it unlikely that this discussion would have resulted in admission for Karen on that date, but it may have prompted further physical health checks in the period which followed. I found that this did not cause or contribute to her death however, as the consultant was well aware of Karen’s presentation and risks, and these were explored in more detail in the reviews which followed.

Action should be taken

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe you have the power to take such action.

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Report details

Reference: 2026-0384
Date of report: 31 July 2026
Coroner: Victoria Davies
Coroner area: Cheshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Nov 2026 (estimated from the Judiciary.uk publication date).

Sent to

Royal College of Emergency Medicine

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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