Finding into death of Gayle Maree Johnson
Deceased
Gayle Maree Johnson
Demographics
51y, female
Date of death
2008-05-03
Finding date
2012-04-12
Cause of death
Complications of anorexia nervosa
AI-generated summary
A 51-year-old woman with severe anorexia nervosa, BMI 12.1, was admitted to hospital acutely unwell with hypothermia, bradycardia, heart block, and extreme malnutrition. She was discharged after only 2 days with minimal medical follow-up and no daily support at home, dying 48 hours later. Critical failures included: lack of capacity assessment despite evidence of cognitive impairment from starvation; no communication between medical and psychiatric teams about discharge planning; discharge despite her refusal to eat and presence of life-threatening cardiac arrhythmias; and absence of daily supervised care on discharge. Expert opinion indicated she should have been involuntarily detained for stabilization and transfer to specialist eating disorders unit, or if discharged, required daily medical and nursing support. The hospital failed to recognize that severe malnutrition impairs judgment and higher-order cognition even when patients appear oriented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Severe anorexia nervosa with BMI 12.1
- Inadequate psychiatric assessment failing to account for cognitive impairment from malnutrition
- Failure to involuntarily detain despite severe medical instability and impaired judgment
- Premature discharge without specialist input despite life-threatening cardiac abnormalities
- Absence of daily medical and nursing support following discharge
- Poor communication between medical and psychiatric teams
- Discharge planning based on hope rather than structured risk assessment
- No liaison with home support or designated carer
- Refusal to eat and continued laxative abuse not addressed in discharge planning
Coroner's recommendations
- Implementation of structured communication policies between medical and psychiatric teams for patients with eating disorders
- Development of a documented guide and education program for management of severe eating disorders
- Education for medical and nursing staff on cognitive implications of severe physical illness and eating disorders
- Appointment of mental health nurse practitioner to improve initial assessment of patients with mental health problems in Emergency Department
- Ensure that discharge decisions for high-risk patients are made at consultant level with input from both medical and psychiatric specialists
- Establish protocols for daily medical and psychiatric assessment of patients with severe eating disorders prior to discharge
- Develop risk assessment tools that account for cognitive impairment from malnutrition, not just electrolyte stabilization
Full text
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