Coroner warns ‘we are swimming in the dark’ when it comes to treating patients with eating disorders

A coroner who has overseen inquests into five anorexia deaths has warned there is a “level of ignorance” among medics about the illness that needs to change.

Sean Horstead expressed disbelief that experts were still “wringing their hands” about the disease eight years after the death of Averil Hart, 19, and multiple reports about the catastrophic failings in her care.

He said there were “a number of features that need addressing urgently” including the need for specialist training for all who work with eating disorder patients, from healthcare assistants to consultants.

Mr Horstead, Cambridgeshire assistant coroner, also warned that until the increasing number of anorexia deaths were properly and robustly recorded, “we are swimming in the dark”.

He added: “I am determined to identify some way in which progress can be made in recording the number of deaths from, or in connection with, anorexia.

“Because if the broad statistic appears to have an anecdotal feel to it, and isn’t backed up with clarity and precision, then it may just drift as an interesting curiosity rather than the fuel for an absolute imperative to address this disease.”

He added: “The statistic that it has the highest mortality of any mental health illness speaks for itself.”

Mr Horstead ruled Ms Hart died due to “gross” and systematic NHS failings and neglect.

As he concluded a three-week hearing at Peterborough Town Hall, he listed a series of “missed opportunities” and failings in Miss Hart’s care, including the allocation of an “inexperienced and inadequately trained” psychologist and a failure to speak to her father, Nic Hart, when he raised concerns with medics shortly before her death.

In the past year, Mr Horstead has also overseen inquests into the deaths of Maria Jakes, Emma Brown, Madeleine Wallace and Amanda Bowles had already concluded.

The coroner was keen to stress that each woman had had a different experience but said a common theme was the absence of a “formally commissioned provision” for the monitoring of anorexia sufferers, particularly those with moderate to severe illness.

“GP practices are trying to wrestle with one of the most challenging or conceivable combinations of physical and mental ill health and are doing so, in my view, often with one hand tied behind their backs,” he said.

“It is that lack of a formal commissioned monitoring service for this cohort of mental health sufferers that causes and contributes to the miscommunication between primary and secondary care.”

He said that GPs are “generalist by definition” but that it was also “unreasonable” to expect “hard-pressed secondary services to be entirely responsible without commissioning of a service”.

Mr Horstead described the current situation as “something of a postcode lottery” and said he would write to NHS England with his concerns.

He will also contact the Royal College of Psychiatrists and the General Medical Council with concerns over education and training. 

He will also write to the Office for National Statistics and the “appropriate office within the coronial jurisdiction” about a lack of data on eating disorder occurrence in the UK.

Mr Horstead ended on a positive note, saying: “There’s a hope that the tide can be turned.

“I hope the five inquests that have been heard in this jurisdiction can be the start of that in some small way.”

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