An anorexic and bulimic woman died weighing just three stone following a ‘catastrophic collision of failures’, a coroner has ruled.

Due to her eating disorder, Nichola Lomax (36) died from liver failure on August 3, 2020 at Fairfield General Hospital, Bury, Greater Manchester. 

Ms Lomax, from Radcliffe, near Bury, had been prematurely In the three months before her death, she was discharged from hospital three more times.   

Joanne Kearsley was the senior coroner in Greater Manchester North. She concluded that her death was due to the physical complications and neglect of her mental disorder. 

She spoke at the Rochdale Coroner’s Court inquest about her death and told Ms Lomax’s relatives: ‘Nichola wanted better. It was an extraordinary young lady who will be remembered forever. 

Nichola Lomax, 36, died of liver failure at Fairfield General Hospital in Bury, Greater Manchester in 2020 as a result of her eating disorder

Due to her eating disorder, Nichola Lomax (36), died in Fairfield General Hospital, Bury, Greater Manchester, in 2020.

“Nichola will be a change.” Now she is making a difference… Nichola’s involvement will help to bring about changes in Greater Manchester regarding eating disorders services.

Ms Kearsley stated that Ms Lomax was a remarkable case because she saw more than 30 doctors in six months before her death. 

Ms Lomax had an 18-year history of the eating disorder and had been admitted to hospital several times throughout her life, but by 2017 she had ‘disengaged’ with specialist eating disorder services.

Radcliffe Medical Practice began to monitor her from that moment on.  

On January 15, 2020, Ms Lomax’s condition was life-threatening and she was advised to go to Fairfield’s A&E unit. On March 23, and April 28, she also visited the A&E unit. 

‘On each of these occasions there was a failure to recognise the severity of her condition and to admit her for a period of medical stabilisation,’ said Ms Kearsley.

“Under the Northern Care Alliance Trust” [which runs the hospital]Own policy she would have been allowed to stay for seven days. 

In addition, said Ms Kearsley there was a failure by the Trust to disseminate the MaRSipan guidelines, which gives clinicians key advice on how to treat patients with eating disorders.

Ms Kearsley continued, “This guidance wasn’t known or followed at any Nichola admission and on each occasion she was discharged.”

“All these factors contributed to Nichola’s death, on the basis of probabilities.”

After being diagnosed with a serious physical condition, Ms Lomax visited her GP and saw an advanced physician.

Fairfield General Hospital admitted her until June 3.

There were several failures in this period, according to Ms Kearsley.

Senior coroner Joanne Kearsley concluded that Ms Lomax 'died as a result of the physical complications of the mental disorder anorexia nervosa and contributed to by neglect' during an inquest at Rochdale Coroner's Court (pictured)

Joanne Kearsley (senior coroner) concluded that Ms. Lomax died due to the physical complications of anorexia nervosa, and she was also neglected during an inquest at Rochdale Court.

She stated that she was not able to take her to the hospital to stabilize her because of her risk of developing refeeding syndrome. This had been previously acknowledged in her previous visits.

“There was not enough basic diet advice. It was difficult to follow the limited advice of these dietitians.

There was no clear plan as to how Nichola would be treated, except to stabilize her. It was difficult to monitor Nichola, and there was inadequate nursing input.

“There wasn’t enough understanding of the input from psychiatry, and there was no effort to engage or seek out specialist services for eating disorders.

“There was a failure of discharge information being provided to the GP. There was also a lack of knowledge or consideration of MaRSipan guidance.”

According to the coroner, these failures were also responsible for Ms Lomax’s suicide.

Ms Lomax went back to the GP office on June 5, 2012. Once more she was referred to A&E.

Her support letter advising that she needed to admit her for stabilisation was received.

Doctors were requested to visit the Priory of Cheadle. The patient was taken into hospital and kept there until June 11. According to Ms Kearsley, there were many failings in her admission.

“There wasn’t a clear plan to treat Nichola with regard to feeding her tube or not,” she stated.

She stated that she did not have a plan and had no conversation with me about accepting tube feeding.

‘There was no close monitoring of her food intake, and there were no purges. [vomiting]Behaviors, and not prescribed supplement drinks

“There wasn’t the basic medical care that you would expect from a person with anorexia or bulimia who’s in life-threatening conditions.”

The coroner concluded her story by stating that there had not been specialist nutritional input requested. Management should have been notified if this was happening.  

Fairfield had a dialogue with the Priory on June 11.

Ms Kearsley said that the conversation had been misinterpreted.

She said that the Priory was convinced Nichola was not interested in admission to the specialist unit for eating disorders and removed her from the wait list.

The misunderstood assumption that Nichola had been discharged was incorrect. She was actually being treated by the community mental healthcare team. However, this was not correct.

“The community eating disorder services had left a note in Nichola’s file that gave the impression that Nichola was being taken care of and would be monitored by them.

“Nichola was wrongly discharged, and there were missed chances for her to be assessed for risk of transfer to a specialist in eating disorders or, if she could not find a bed, escalate to NHS England.

According to the odds, her death was likely caused by or contributed to all these failures that occurred between June 5th and 11.      

To prevent more deaths, the coroner stated that she would prepare a Report 28.

Ms Kearsley explained that Nichola died from a tragic collision of failures. This was my view long before any doctors were ever involved.

Will Blandamer (executive director of strategic Commissioning, Bury One Commissioning Organisation) said in the aftermath of the inquest: “On behalf Bury NHS Clinical Commissioning Group we offer our sincere condolences for Nichola and her family.

The CCG recognized that there were gaps in the services that could be provided to patients at hospital. They are currently working with other stakeholder, such as mental health trusts and acute trusts to address that gap.

“We have committed to expanding the adult eating disorder service, which is a new model that includes MaRSiPAN guidance and will result in significant improvements throughout Greater Manchester.