Inquest opens into death at unit of woman with anorexia

AN inquest has begun into the death of a 22-year-old woman who died while being treated at a specialist eating disorders unit in Exeter.

Zoe Clark was battling anorexia nervosa when she died at The Haldon unit at Wonford House on August 22, 2017.

An inquest into the circumstances around her death, including the management of her care while at the unit, started yesterday.

Her family said in a statement they had concerns that the unit, which is run by the Devon Partnership NHS Trust, had not adequately considered Zoe’s risk of suicide.

“We’ve lost our wonderful daughter and we’ll never be the same without her. We hope her death will not be in vain and the Devon Partnership Trust will learn lessons,” the family said.

Zoe, a former Exeter College student and waitress at Cofton Holidays, had been detained by the state as a vulnerable individual three weeks before her death. The inquest was given details about the circumstances leading up to the tragedy.

Mr Philip Spinney, HM Senior Coroner for Exeter, said Zoe had been diagnosed with anorexia nervosa as a teenager and had been receiving support from specialist children and later adult health services since then. Her treatment included several inpatient admissions to the Haldon unit, which is based near the Royal Devon and Exeter Hospital.

In June, 2017, she was discharged from the unit but readmitted under the Mental Health Act on July 31 for breaching her community treatment order. Her Body Mass Index had dropped below 16, a level associated with being underweight.

She received treatment for the disorder at the unit and was subject to hourly room checks, but at 1am she was found unconscious in her room. Paramedics and staff tried to revive her, but she died. The cause of death was hanging.

The inquest is being held in front of a jury due to the fact Zoe died in a secure hospital setting.

In a statement, her mother, Gail, said she was “convinced, if Zoe had been at home, she would be alive today”. She said the family’s main concerns related to the Devon Partnership Trust and the adequacy of the Haldon Unit to monitor her and consider her suicide risk. They also say she should not have had access to the means to kill herself.

Zoe’s mother said a number of factors would have heightened Zoe’s suicide risk. These included her feelings that she was “a prisoner” at The Haldon and that she started selfharming again. She also feared she might stay in the unit forever, having not been given a discharge date. Her mother said Zoe also despised what she called ‘weigh day’, when patients’ weights were recorded.

Home Office pathologist Dr Amanda Jeffery said Zoe weighed 7st 8lb after death and her BMI reading was 18.5, which put her borderline between healthy and underweight. There were no illicit drugs or alcohol in her system when she died.

Apart from her obvious eating disorder, Zoe was otherwise relatively healthy, said the pathologist.

The coroner told the jury that the inquest, which is due to last four weeks, would examine events before Zoe was admitted to The Haldon and also her management while on the unit and at the time of her death.

It will hear evidence from health professionals who were in charge of her care and also details of the relevant policies and procedures.The jury will establish the facts and reach a conclusion about how she died.