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Doctor error contributed to anorexic woman's death, Coroner says.


A decision not to "urgently" refer an anorexic woman, whose condition had significantly deteriorated, contributed to her death, a coroner said.

The woman, Amanda Bowles, 45, who the inquest heard was discharged from an eating disorder service in spite of having a ’critical BMI’, was found dead at her Cambridge home in September 2017.

An eating disorder psychiatrist who assessed her on 24 August that year apologised to Ms Bowles' family for not organising an admission under the Mental Health Act.

Assistant coroner for Cambridgeshire and Peterborough, Sean Horstead, said the decision not to arrange an assessment "contributed to her death.”

Mr Horstead told an inquest in Huntingdon that, on the balance of probabilities, the "decision not to significantly increase the level of in-person monitoring" following 24 August "contributed to the death.”

A clinical psychiatrist at Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), Dr Jane Shapleske, went to Ms Bowles home to assess her following serious concerns from a GP.

During the assessment Dr Shapleske found the mother-of-one's health had "significantly deteriorated" and she "was at a high risk of death".

She told the inquest she regretted not organising an admission, but felt Ms Bowles, who was also agoraphobic, would agree to a voluntary admission when a bed became available and would have been less receptive to treatment had an admission been forced/more

Mr Horstead told the inquest: "The level of physical risk was identified. but the urgency to act on the medical risks was absent. No additional safeguarding arrangements were made to closely monitor any further deterioration" in the interim period between the assessment and admission.”

The inquest was also told that, following Ms Bowles discharge from CPFT's Adult Eating Disorder Service (AEDS) in December 2016, her condition was not monitored until May 2017 when a doctor noted she "hadn't been reviewed for some time, seems to have fallen through the net.”

In his narrative conclusion, Mr Horstead said it was "possible that, had a robust system for monitoring Ms Bowles in the months preceding her death been in place, the deterioration in her physical and mental health may have been detected earlier and led to an earlier referral to AEDS.”

He said this absence "was the direct consequence of the lack of formally commissioned monitoring in either primary or secondary care for eating disorder patients".

Mr Horstead concluded this absence "possibly contributed to Ms Bowles' death".

A spokeswoman for NHS England and NHS Improvement in the East of England, said they were "committed to expanding and improving access to eating disorder services in the community. There has been continued investment in Cambridgeshire and Peterborough to further improve how adult eating disorder services work together."

The inquest in Huntingdon was the latest to be heard relating to a cluster of five deaths of people with anorexia between 2012 and 2018.