Failures contributed to death of anorexia patient being treated in Ipswich

An inquest concluded that failures led to the death of Hayley Smith, who was being treated in Ipswich

An inquest concluded that failures led to the death of Hayley Smith, who was being treated in Ipswich - Credit: Supplied by family

A series of failures led to the death of a young woman who was being treated for anorexia nervosa at a specialist clinic in Ipswich, an inquest has concluded. 

Hayley Smith was a patient at the White House in Ipswich but at the time of her death, the 27-year-old was on home leave from the Suffolk rehabilitation unit. 

Miss Smith, from Sturry, near Canterbury, Kent, died on December 29, 2019, at the Queen Elizabeth the Queen Mother Hospital (QEQMH) in Margate after suffering heart failure caused by her malnourished state.

Miss Smith was granted home leave six days before her death for Christmas, but the jury concluded that the family was given "insufficient and inadequate information" to support her during her home leave. 

During the eight-day inquest at North East Kent Coroner's Court, the jury heard how Miss Smith was under a community treatment order which meant she could have been sent back to hospital if she failed to comply with conditions set by the responsible clinician. 

An ambulance was called by Miss Smith's family on December 23 after she collapsed at home due to low blood sugar. 

She was given glucose and refused to be taken to hospital. 

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On Christmas Eve, Miss Smith was taken to the QEQMH accident and emergency (A&E) department, who thought she had capacity to decide to go home. 

The jury heard that neither the paramedic attending on December 23, nor the A&E nurse on December 24 was aware of the community treatment order, or the fact that Hayley was under the care of the team at Canterbury.  

On Christmas Day, after Miss Smith’s family found her unconscious in bed and an ambulance was called, she had a cardiac arrest which caused oxygen deprivation and brain damage. She was taken to QEQMH where she died three days later.

Coroner Catherine Wood said she plans to write to the Department of Health and NHS England, and will issue a prevention of future deaths report about information sharing. 

The inquest also heard Miss Smith had not had a blood test for three months before she died. 

With no similar provision for eating disorder patients in Kent, the White House was the nearest service provider available to offer suitable help. 

The 240-mile round trip from Canterbury to Ipswich made visiting "almost impossible" for the family. 

In a statement, Miss Smith's mother, Ann Smith, said: “Hayley had suffered from anorexia from a young age and she had been receiving treatment throughout her teenage years and into adulthood.

"However, her condition worsened instead of improving. Finally, the NHS hospital where she was receiving care decided she would make progress in community care. We felt that this wasn’t the case and to make matters worse, Hayley was put into a rehabilitation unit 120 miles away where we were unable to give her the family support she needed.
“While she was at the unit, she didn’t received the care and support that she needed, and when she was sent home for Christmas her condition was so low that we feel that without the expert help she needed, she was in a desperate state. We feel that our Hayley lost her life because she didn’t receive the care to which she was entitled.”

Solicitor Yvonne Kestler, from Leigh Day, who represented the Smith family, said: “Hayley’s family did their absolute best to support her through all the years she suffered anorexia nervosa, a recognised mental health condition.

"When Hayley was transferred to the White House she was already considered “high risk”. That is why it was essential that her community treatment order was complied with. More steps should have been taken when Hayley failed to comply.

“We are grateful to the coroner for recognising the significance of Hayley’s case and for helping the jury to understand how to address the issues they heard.”

A spokeswoman for the White House said: "We would like to once again offer our heartfelt condolences to Hayley's family and friends. 

"Although Hayley had struggled with severe and enduring anorexia nervosa for many years, her death came as a great shock to everyone at the White House.  

"Hayley wanted to spend Christmas with her family and, at the time, it was believed that she was well enough to go home for a visit.  

"The inquest has highlighted a number of areas where the communication between the organisations caring for Hayley should have been better, and the coroner is to write to the secretary of state for health, and NHS England, about the national learning from Hayley’s sad death.

"We have made a number of changes since Hayley’s death in 2019, and we have listened carefully to all the evidence throughout the inquest.  

"We will reflect upon everything that we have heard, as we continue to strive to ensure best practice, with clear communication with individuals, families and all of the agencies involved in caring for the people that we support."

Jodie Anderson, senior caseworker at charity INQUEST, said: “Yet again this is a case where the needs of a young woman in crisis were completely ignored.

"Hayley’s family had every right to expect that she should be kept safe by health professionals, and be returned home when it was appropriate. Yet it was obvious to them just how ill she was when she got there.

“Specialist care for people with eating disorders is too often failing to meet their needs. It is frequently far from home and does not provide adequate support.

"Eating disorders have the highest mortality rate of any mental illnesses. We must see more action in response to this case to ensure other women and people with eating disorders are better protected.”