The heartbroken family of a children’s nurse who died a day after visiting A&E are calling for emergency departments to improve the way they treat patients with eating disorders.
Kim Dyer, 31, rapidly lost weight in the days before her death and was taken to King’s College London with low blood sugar twice in the two days before her death.
She was treated but waited for hours in the emergency department for a hospital bed, before discharging herself just after midnight on November 28, 2018.
The mother-of-one, who was a pediatric nurse at Chelsea and Westminster Hospital, was found dead by her partner the next morning.
An inquest at Southwark Coroner’s Court heard doctors and nurses in King’s A&E had little experience with patients with eating disorders and were not aware of guidelines for the ‘management of really sick patients with anorexia nervosa’ (MARSIPAN).
The court heard if guidelines had been followed, Kim would not have been allowed to discharge herself without seeing someone from the psychiatric team.
The coroner also heard doctors at South London and Maudsley NHS Trust (SLAM) were looking for a bed at specialist clinics just before Kim’s death, but none were available.
Speaking after the hearing, Kim’s father Gordon said Eating Disorder Units are “grossly underfunded” and the family were “disappointed” the coroner did not find any gross failures by SLAM.
He said: “I think the psychiatric team really worked their hearts out for her. The only disappointing part from our point of view was the lack of supervision of her while she was in community care.
“I don’t think anybody actually visited her flat. As it became clear it was just a gymnasium for Kim to exercise unsupervised.
“She was seen once a week and as her condition deteriorated she was seen twice a week, but clearly her physical condition should have rung some kind of alarm bells with them that something wasn’t working.”
Following the inquest King’s College has created a new policy to deal with patients with eating disorders in the emergency department.
Mr Dyer said: “It’s all very well saying this should happen but whether it has been put into practice, we don’t know. We hope it will stop someone else going through what we have.
“The inquest highlighted the lack of knowledge around eating disorders within the NHS generally.
“It’s not the A&E doctors not knowing, somewhere along the line the whole medical care system isn’t joined up enough. The problem is national.”
Kim suffered from an “enduring eating disorder” that started when she was 12.
She had been admitted to hospital and clinics multiple times over the years, the inquest heard, but was discharged around two months before her death so she could live at her flat in Battersea, south London.
Dr Nikola Kern, Kim’s psychiatrist, told the inquest: “She was a particularly worrying case, one I have rarely seen in my whole time.
“From the outside it would look as if this was a severe or even critical BMI, and someone shouldn’t be in the community like this.
“But there was no other way to help her to have some kind of life outside of hospital, the option would have been either staying in hospital forever or having a high risk plan like this.”
Laura Davis, an A&E sister nurse, said when Kim came in there were 21 people in A&E waiting for a bed, and a wait of seven-and-a-half hours.
Mrs Davis said Kim told her she wanted to go home as she was tired and it was too loud to sleep on a chair in the A&E corridor.
She said she had not come across MARSIPAN ( Management of Really Sick Patients with Anorexia Nervosa) and would have acted “very differently” if she had.
She said: “I definitely wasn’t aware of the magnitude of her eating disorder. People are becoming more aware of it but we are not quite there yet and sadly I didn’t know about it then.”
Kim was also spoken to by Dr Dominic Craven that night, who told the coroner he rarely encountered patients with serious eating disorders in A&E.
He said it was “very rare” to get second opinions from the psychiatric team if the patient appears to have capacity to make decisions about their care – which he felt Kim did.
But he admitted there was “quite a poor understanding” of assessing ED patients and even after discussing the case with colleagues, the MARSIPAN guidelines were not mentioned.
Dr Craven said: “If we were given a heads up about the gravity and that she can’t leave, then we would have got the psychiatric liaison team and put more pressure on them to see her.”
The coroner also heard waiting times in A&E at the time were “pretty dire” at the time and eight hour waits were “common but a reality” in winter.
Dr Sinead Scullion, a consultant in emergency medicine, told the coroner a team of 24 emergency consultants did not know MARSIPAN existed.
She said: “I think the department should have asked for a mental health assessment of Kim, but they didn’t know that was part of an assessment for a patient with a severe eating disorder… that’s more a reflection of a wider training issue in emergency departments as a specialty.”
Dr Scullion said more has been done to improve waiting areas at King’s, with comfier chairs and moving patients from A&E to ward waiting areas.
Giving a conclusion of natural causes, assistant coroner Henrietta Hill QC said: “The MARSIPAN guidelines make clear that high risk patients like Kim should not be discharged without psychiatric input.
“There is insufficient evidence the means she died was accidental, but a wealth of evidence she died of a natural cause of her eating disorder.
“There is insufficient evidence that the failure by SLAM to refer her to casualty any earlier was gross.”
Ms Hill said she would send a Preventing Future Deaths Report to the government about the MARSIPAN guidelines, and the national shortage of beds for patients with eating disorders.
Paying tribute to his daughter, Mr Dyer said: “She was a very determined and caring person, she loved being a nurse.
“Her crowning glory was when she saved a baby’s life. She loved children from an early age, even at about three or four years old she would look at a baby and say ‘auntie Kimberley will look after you’.
“Everyone thinks it’s just a phase young women go through with their appearance. So it took quite a while for all of us really to understand this was a mental issue.
“When I saw her in hospital she had pictures of her as a bridesmaid at her brother’s wedding on the wall, and she looked beautiful, she looked stunning. I asked what she saw when she looked at it and she said ‘fat’.
“She used to say she heard voices telling her not to eat, she said she’d like some food but she was being told not to eat it. You can’t get past that mindset – they have got to find it themselves, got to want to do it.”