Eating disorders can be complex conditions for clinicians to manage. Dr Emma Davies, Medicolegal Consultant at Medical Protection, looks at a case of anorexia that resulted in our member being called to an inquest.
Anorexia is a complex, potentially life-threatening mental health illness that predominantly affects women, but there is an increasing number of cases involving men in recent years.
The complexity comes from the behaviour of sufferers who may function for significant periods of time, masking their condition and appearing to be otherwise well. However, the line between being at a low BMI and stable, and becoming critically ill, can be a matter of kilograms and this can occur rapidly at times of crisis. The interplay between capacity in the face of a mental health illness can lead to doctors assuming that they cannot intervene.
At Medical Protection we have assisted doctors and healthcare professionals through difficult complaints and inquests relating to anorexia and there are common themes in these cases. In this article we look at these common themes and how Medical Protection assisted a member in an inquest case.
Case study
In this case the patient, Mrs A, a lady in her 30s, had a long history of anorexia since her teenage years. Her daughter was diagnosed with a life-limiting condition and her long-term relationship broke down. Her BMI had been 14 for many years but she entered a crisis phase and almost stopped eating all together. Soon her weight dropped from 34kg to 29kg. With the patient’s consent the GP contacted the Eating Disorders Team (EDT) and after a few weeks of persuasion and delays Mrs A was admitted to hospital where she accepted NG feeding. She did regain her weight and was discharged with a plan for the EDT to continue to monitor her bloods, weight and ECGs every 2-3 weeks. By this time the COVID-19 pandemic had hit.
Once out of hospital Mrs A did not engage with the EDT and the GP who had been looking after her went on long-term sick leave so our member, Dr B, a locum GP, took over her care. The EDT discharged Mrs A because of non-engagement and advised the practice to continue to monitor Mrs A every 2-3 weeks.
Dr B reviewed Mrs A regularly but often Mrs A refused to be weighed and despite Dr B going to see her at home (an unusual event during the first wave of the pandemic) it was difficult to persuade her to have her bloods taken. Dr B therefore focused on trying to gain rapport with Mrs A and to engender a trusting doctor-patient relationship. It was obvious to Dr B that Mrs A was again losing weight but Dr B felt that Mrs A had capacity and was also somewhat reassured by the fact that Mrs A had been chronically underweight for all her adult life.
Mrs A’s family raised concerns to the practice about Mrs A; they felt that she was getting critically ill again and was probably at a similar weight to when she had been recently admitted. Dr B went to visit Mrs A and spent a long time with her discussing her family’s concerns, and the clinical concerns that she was at risk of becoming critically ill, including the risk of death. Mrs A appeared to understand the concerns and accept them but she was adamant she did not want to go back to hospital as she needed to be home for her daughter. She did, however, agree to blood tests, which showed that she was mildly anaemic and her ALT was raised on her liver enzymes. Mrs A agreed to attend the practice for an ECG the next day.
Four days later the practice were informed that Mrs A had collapsed at home and had been taken into hospital where she had died from multiorgan failure secondary to anorexia. An inquest was opened, and Dr B was asked to provide a medical report.
A Medical Protection medicolegal consultant met with Dr B to go over the case. Medical Protection had experience of this coroner, with a past case of a patient dying of anorexia where the healthcare professionals had been criticised, so we were alert to this being a potential risk for Dr B. During the meeting we identified the areas the coroner would be likely to explore; these were the assessment of Mrs A’s capacity and the interpretation of her abnormal blood results.
During the meeting Dr B talked about his thought processes around Mrs A’s capacity and how he had come to know her well over the months since her discharge from hospital. He also relayed that in the lead up to her admission Mrs A had been assessed by a psychiatrist, who had deemed her to have capacity at that time. It became apparent that Dr B was not aware of the MaRSiPAN guidance regarding the management of patients with anorexia. With this in mind the medicolegal consultant advised Dr B and the practice to hold an SEA to discuss Mrs A’s case, identify areas of improvement in either knowledge or process and to put an action plan in place. The medicolegal consultant assisted the practice by suggesting they focus on the following questions:
- Should Mrs A have been re-referred to the EDT?
- Did Mrs A have capacity and what was considered in the capacity assessment?
- Are the GPs aware of the MaRSiPAN guidance and how would it have applied to Mrs A’s case?
Given the likelihood of Dr B being called to give evidence at the inquest and the possibility of him being an Interested Person, Medical Protection instructed a solicitor to assist with drafting the report to ensure we could get as much of the relevant information across to the coroner as possible.
Subsequently Dr B was called as an Interested Person and we arranged for a barrister to provide him with legal representation and to prepare Dr B for giving evidence. When giving evidence, with the questions put to Dr B by the barrister, he was able to convey to the coroner how much input and thought he had given to Mrs A’s case and to explain his rationale for deeming her to have capacity despite having a significant mental health crisis.
Dr B’s evidence, the robust SEA and the completion of the action plans by the practice assured the coroner that a prevention of future deaths report was not indicated. The coroner gave a short narrative verdict and concluded that Mrs A had died of natural causes secondary to anorexia nervosa.