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Coroner's report urges action to prevent more eating disorder deaths.


Failures to protect a gifted teenager with anorexia risk being repeated and might lead to more deaths if health bodies fail to take action, a coroner has warned in a new report.

Suffolk teenager, Averil Hart, 19, died in December 2012 after losing weight during her first term at the University of East Anglia. 

The coroner ruled in November 2020 that her death at Norfolk and Norwich University Hospital, where she was rushed to after collapsing on December 7, 2012, was avoidable and contributed to by neglect.

Her inquest heard doctors failed to provide any nutritional support in her four days on the ward when she rapidly deteriorated and later died after being transferred to Addenbrooke’s Hospital, Cambridge. 

Assistant Cambridgeshire coroner, Sean Horstead, also oversaw the separate inquests of anorexic women Maria Jakes, Emma Brown, Madeleine Wallace and Amanda Bowles.  

All five deaths are referred to in a ‘prevention of future deaths report’ published  by Mr Horstead, which focuses on Averil Hart’s case. 

In the report, he says: “For all of these women anorexia nervosa was the medical cause of death; to a significant degree. The five inquests shared common themes of concern.  There is a risk that future deaths could occur unless action is taken.” 

Addressed to health secretary; NHS England, the General Medical Council, and training bodies Health Education England and the Academy of Medical Royal Colleges, the report urges action on four main concerns. 

These include: ‘Inadequate’ training of doctors and other medical professionals around eating disorders; a lack of formally-commissioned monitoring of moderate to high-risk anorexia nervosa patients by primary or secondary care providers; a lack of robust and reliable data on the prevalence of eating disorders and the effect of the Covid-19 pandemic on medical training and availability of data.

Mr Horstead is also planning to explore the recording of eating disorder deaths with the Medical Examiner for England and Wales, the Office for National Statistics and the Coroners’ Society of England and Wales. 

His report adds: “In my view, taken together, the absence of statistically robust data on the numbers of those suffering from eating disorders, and the potential under-estimation of those deaths to which eating disorders may have caused, or contributed, gives rise to an objective risk that avoidable eating disorder deaths will continue in the future.” 

During Averil’s inquest, the coroner described a “level of ignorance” of anorexia among health professionals. This was echoed in the treatment of all five women. 

Gaps in community eating disorder care, which the coroner likened to a ‘postcode lottery’ in the east of England where medical check-ups typically fell to GPs, were also identified. 

Medical director and director for education and standards at the General Medical Council Professor, Colin Melville, said: "Eating disorders are a complex, high-risk area of practice that should be covered in every doctor’s education.

"We’re carefully considering the coroner's recommendations as we continue to work with stakeholders to drive change. We’ve asked medical schools to address knowledge gaps and agree a common approach to improve the way eating disorders are taught at medical school.

"New resources covering early diagnosis, monitoring and treatment, are now in development with experts from eating disorder charity, Beat, and the Royal College of Psychiatrists, to support students, trainees and practising professionals with updated information.

"Better education, along with system-wide reform, is crucial to prevent more avoidable deaths, and to help more patients recover."