A coroner will be preparing a Prevention of Future Deaths report to look into the circumstances of the deaths of five women who all suffered from eating disorders.
Assistant coroner for Cambridgeshire and Peterborough, Sean Horstead, was hugely critical of the current provision in Cambridgeshire and Peterborough for patients with anorexia and described the level of care available as a “lucky dip” and said successful treatment was “reliant on the goodwill of GPs”.
Mr Horsted has been presiding over the inquests into the deaths of Averil Hart, Emma Brown, Maria Jakes, Amanda Bowles and Madeline Wallace. All five women died between 2012 and 2018.
His report is likely to call for better monitoring of people with eating disorders and improved clinical training.
Cambridgeshire and Peterborough Foundation Trust (CPFT), which runs the eating disorders service all five women used, told the BBC it was “committed to supporting further developments regionally and nationally”.
One those who died was former Longsands Academy student Emma Brown who was aged 27. She was found dead in her flat, in Cambourne, by her mother in August 2018.
Emma, the eldest of three children, had been diagnosed with an eating disorder in her teenage years, and then at the age of 18, was diagnosed with a personality disorder. She had been receiving treatment on and off since her diagnosis.
Emma was talented when it came to sport, and was a keen runner, running for 15 miles a day. She was also a member of Swans Swimming Club, in St Neots.
The Hunts Post covered Emma’s inquest when her father described his daughter’s illness as a “descent into hell”.
He said: “This is an illness where the patient feared weight gain, she feared recovery, so fought against the help that was being offered.”
A post-mortem examination gave Emma’s cause of death as lung and heart disease, with anorexia and bulimia nervosa as contributory factors.
An NHS spokesman told the BBC: “The important and deeply concerning findings and learning set out by the coroner must be acted on by all those services involved.
“The NHS will continue to expand and improve access to eating disorder services, including in Cambridgeshire and Peterborough, to strengthen how adult eating disorder services work together.”
INFO: Call eating disorder charity helpline: 0808 801 0677 or youth helpline on 0808 801 0711.