Coroner Calls On Government To Take Action To Improve Diabetic Eating Disorder Care Nationally Following Hertfordshire Teacher’s Death

A coroner has called on the government to take action after an inquest found a teacher may have died because of a lack of integration between mental health and physical healthcare systems and an absence of pathways of care for Type 1 Diabetes with Disordered Eating.

Megan Davison was found deceased at her home, having taken her own life, in August 2017. The 27-year-old had been suffering mental health issues and was suffering from Type 1 diabetes with Disordered Eating (T1DE), formerly known as diabulimia.

Family instruct specialist public law and human rights lawyers

An inquest in March 2018 concluded the cause of Megan’s death was suicide.  However, Megan’s family were unhappy that the inquest did not investigate the treatment she received for T1DE. They instructed specialist public law and human rights lawyers at Irwin Mitchell who successfully applied to the High Court which quashed the first inquest and ordered a second hearing be heard.

Her family have now spoken out after the second inquest concluded Megan, of Cheshunt, Hertfordshire, died by suicide in the context of T1DE.

Coroner issues Prevention of Future Deaths Report

Assistant coroner for Hertfordshire, Alison McCormick, issued a prevention of future deaths report, calling on the government to set out what action it will take to improve patient care.

It comes after the coroner raised concerns that on a national level, there is no system capable of being operated in a way to ensure proper integrated healthcare for patients with T1DE.

“There is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for diabetic ketoacidosis (DKA), an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm”, Ms McCormick wrote.

Other issues raised as making a contribution to Megan’s death

Other issues raised as making more than a minimal contribution to Megan’s death included: her discharge from the care of a mental health trust; a lack of integration between physical and mental healthcare systems and a lack of consolidated records and communication between different parts of the healthcare system.

Parents call for lessons to be learned from Megan’s death to help others

Megan’s parents, Lesley and Neal, have now joined their legal team at Irwin Mitchell in calling for lessons to be learned from Megan’s death to help others.

Lesley said: “It’s impossible to find the words to describe the pain we’ve felt since losing Megan. There isn’t a day goes by when we don’t miss her, our daughter was a very special and much loved individual.

“We’re so grateful that we were granted this second inquest so that Megan’s condition could be investigated sufficiently.  While it doesn’t change what happened, and the hearing has again been tough to get through, we now have some answers to the questions we’ve been asking for seven years.

“We’re also thankful that a national Prevention of Future Deaths report has been issued to the Secretary of State for Health.  While it’s sadly too late for Megan, we hope that this will go a long way in helping others living with T1DE.

“All we can hope for now is that by speaking out we can help raise further awareness of the condition so that others don’t suffer like Megan did.”

Oliver Carter is the specialist public law and human rights lawyer representing Megan’s family

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“This is a truly tragic case, and Lesley and Neal have spent the past seven years struggling to come to terms with losing their daughter but also using their considerable energy and experience to try to save the lives of other people with T1DE.

“The pain and grief Megan’s loved ones feel has understandably been made worse by their wait for a second inquest. While reliving everything again at the hearing has been upsetting, it’s something they had to do to honour Megan’s memory.

“Nothing will ever change what’s happened or bring Megan back, but we’re pleased that we’ve at least been able to provide Lesley and Neal with the answers they deserve.

“It’s now vital that lessons are learned to reduce the risk of others going through what Megan did and, as a result, we welcome the coroner’s decision to issue a Prevention of Future Deaths report to improve patient safety.” Oliver Carter

Deborah Coles, Director at INQUEST, said: “Through the perseverance of Megan’s family, this second inquest has shone a light on the urgent need to integrate mental and physical healthcare systems and to establish proper care for people living with T1DE.

“The Government now have the opportunity to prevent more deaths, but this will only be possible with proper oversight and accountability of actions taken by the NHS at a local and national level.

“The current lack of proper oversight means that potentially life-saving recommendations such as these can end up on a shelf. This fails not only Megan’s family but also the wider public.

“We need a National Oversight Mechanism to address this shocking accountability gap. This would do justice to bereaved families and help protect lives.”

When issuing her report, the coroner also called on Hertfordshire and West Essex Integrated Care Board to improve care for people with diabetes and eating disorders.

The Secretary of State for Health and Social Care and Hertfordshire and West Essex Integrated Care Board are required to respond to the coroner’s report to prevent future deaths by 9 September 2024, setting out the action which they propose to take in response to the coroner’s concerns.

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