Cambridgeshire coroner warns there may be 'significant under-reporting' of extent to which eating disorders have contributed to deaths

Sean Horstead said in a report to prevent future deaths, which was published this week, that this “gives rise to an objective risk that avoidable eating disorder deaths will continue in the future”.

He has sent his report to five parties, including Health Secretary Matt Hancock, and has asked for responses by April 28.

Mr Horstead, assistant coroner for Cambridgeshire said responses “must contain details of action taken or proposed to be taken, setting out the timetable for action”.

He added: “Otherwise you must explain why no action is proposed.”

Mr Horstead concluded last November that the death of 19-year-old university student Averil Hart was avoidable and was contributed to by neglect.

He previously oversaw inquests into the deaths of four other women – Amanda Bowles, Madeline Wallace, Emma Brown and Maria Jakes.

In his report, written after hearing the five inquests, Mr Horstead said there is a lack of training of doctors and other medical professionals about eating disorders.

He added: “I am concerned that there may also be a significant under-reporting of the extent to which eating disorders have caused or contributed to deaths, leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’ with only the terminal cause of death, and not the underlying eating disorder cause or contribution to the death, being recorded.

“In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest, with a risk of a significant under-estimation of the true mortality rate of eating disorders.

“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.”

Mr Horstead also raised concerns about the lack of a commissioned service to monitor moderate to high-risk anorexia patients, and said that problems could be “significantly exacerbated” by the ongoing pandemic.

MORE: Inquest: ‘Neglect and systemic failures caused teenager’s death’