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Further Information

SAR - Miss C (published June 2018)

The Norfolk Safeguarding Adults Board has recently completed an independent intellectual review of a tragic case related to a young woman who died as a result of anorexia nervosa - Miss C. Due to concurrent investigations, and the desire to ensure that all avenues were robustly investigated to represent the facts accurately, there has been some delay in publication of this review. The NSAB partners have agreed to publish the review today, 27 June 2018.

Following referral to the local eating disorder service, Miss C was admitted informally to a specialist eating disorder unit at Addenbrookes Hospital in mid-September 2011. Miss C was discharged at the beginning of August 2012 and, in late September 2012, she started her undergraduate course at the University of East Anglia, living in halls of residence. Her weight dropped dramatically between September and December 2012. On 7 December, Miss C was found collapsed at her student accommodation and was admitted via A&E to the Norfolk & Norwich University Hospital, with low blood sugar levels. Miss C's physical health deteriorated and she was transferred to Addenbrookes Hospital on 11 December 2012. On 12 December, Miss C's condition further deteriorated and, following discussion with Miss C's parents on 13 December 2012, the decision was taken to stop active treatment. Miss C died in Addebrookes Hospital on 15 December 2012, with her family by her side.

Our review into the case of Miss C contains copies of earlier reports, and these are brought up to date in the final review report, dated 15 May 2018, the outcomes of which have been considered by NSAB. The report makes clear:

  • the board is assured of the progress of implementation of outcomes and are monitoring the progress that is continuing to be made
  • overall, there is evidence of substantial actions (taken) to address the recommendations of the expert reports written in 2014

The partners of the NSAB wish to extend their heartfelt condolences to the family in this tragic case, and to thank the independent author and partner agencies for their collaboration in ensuring this report is contemporary in its findings and recommendations.

SAR Miss C final report 15 May 2018