Inquest into the death of Mandy Bowles concludes

The three-week inquest into the death of Mandy Bowles concluded on 18 September 2020, with the Coroner making strong criticism of national commissioning for the monitoring of Eating Disorder (ED) patients, and finding that the decision not to arrange an urgent assessment of Mandy under the Mental Health Act (MHA) for her involuntary admission to hospital, or provide appropriate safeguarding, in the last weeks of her life, contributed to her death.

The facts

Mandy Bowles was found deceased in her home on 7 September 2017, having suffered for a number of years with a Severe and Enduring Eating Disorder (SEED), Anorexia Nervosa (AN), alongside other mental health conditions, including Obsessive Compulsive Disorder (OCD), agoraphobia, anxiety and depression.

Mandy died while in the care of the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) specialist Adult Eating Disorder Service (AEDS). In December 2016, the year prior to her death, Mandy had been discharged from the CPFT AEDS on the basis that she was unable to engage with the service, as her agoraphobia prevented her leaving her home to attend the AEDS practices, she had refused voluntary admission to an AEDS ward, and the AEDS were not commissioned to provide home visits. Indeed, it was confirmed in evidence at the inquest that there was no specialist service (in either primary or secondary care) commissioned and funded to provide monitoring to Adult ED patients in the community at that time.

Upon discharge, the responsibility of monitoring Mandy’s heath was passed to her primary care GP surgery, with instructions from the AEDS that she should be visited at home on a weekly basis.  Sadly, however, due to a breakdown in communication at the GP surgery and disagreement within primary care about which would be the appropriate service to monitor Mandy at home, the discharge plan was not put in place and Mandy remained unmonitored between December 2016 and June 2017.

Indeed, monitoring restarted only after Mandy contacted the AEDS herself in April 2017 and again in May 2017 to inform them that she had not been visited by the GP and that her health was deteriorating. GP evidence in the inquest commented that Mandy appeared to have ‘fallen through the net’.

When monitoring was re-started in June 2017, a lack of consensus surrounding which service should monitor Mandy remained and monitoring, on a fortnightly basis, was delegated to the District Nursing team, despite District Nurses expressing concern that they did not have the relevant expertise or training to monitor a patient with such severe mental health concerns.

Sadly, monitoring by the District Nursing team was patchy and, due to perceived difficulties engaging with Mandy in person, eventually Mandy was referred to ‘Assistive Technology’ which required her to submit her own weight and health electronically. The Coroner, following expert evidence during the inquest that ED patients are often compelled by their condition to falsify recordings sent to professionals, found that this referral was ‘wholly inappropriate’ and ‘was the consequence of well-meaning District Nurses lacking the training, knowledge and experience of AN’.

Due to serious deterioration in her health, Mandy was referred back to the AEDS in August 2017 and urgently assessed by an AEDS consultant psychiatrist on 24 August 2017, who determined that Mandy needed to be admitted to hospital. Mandy’s weight was 28kg and she had a critically low BMI of 10.5.

However, the consultant psychiatrist did not arrange an urgent MHA assessment for Mandy’s admission to a medical ward. Instead, a MHA assessment was arranged for when a bed on a Specialist Eating Disorder Unit (SEDU) would become available some two weeks later. No increased safeguarding or face to face monitoring of Mandy was arranged between this period of assessment and likely admission.

When the MHA assessment team attended Mandy’s home on 6 September 2017 Mandy did not answer the door. A warrant was executed to force entry to her home on 7 September 2017 and Mandy was sadly found deceased, having contracted pneumonia and a possible cardiac arrhythmia.

Conclusion

The Coroner’s conclusion found on the balance of probabilities, that: (a) the decision, following the assessment on 24 August, not to urgently arrange a MHA assessment to facilitate an involuntary medical admission to hospital and (b) the decision not to significantly increase the level of in-person monitoring of Mandy in the period following the assessment on the 24 August, contributed to Mandy’s death.

The Coroner also found that the absence of a robust monitoring system involving face to face consultations with appropriately trained medical practitioners with experience of high risk eating disorder patients, possibly contributed to Mandy’s death.

The Coroner stated that the lack of monitoring of Mandy must be set in the context of the ‘unsavoury reality’ of the structural failure of the state to provide formally commissioned monitoring services of adult ED patients, which has created a ‘lacuna’ in the care provided to vulnerable ED patients that persists on a national scale.

The Coroner will be providing a Prevention of Future Death (PFD) Report.

Saunders Law’s Ruth Mellor and Polly Rodin represented the son of Mandy Bowles in these inquest proceedings, alongside Counsel, Anita Davies of Matrix Chambers.