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A young woman who died of anorexia days after being allowed home from an eating disorder clinic "in a desperate state" was failed by those entrusted to help her, an inquest has concluded.
Hayley Smith was found unresponsive on Christmas Day and died four days later aged just 27 following a breakdown in communication between medical teams.
An eight-day inquest into her death was told blood tests that would have revealed how unwell she was were not carried out, and medics who came into contact with her in the days before her death were not aware of the treatment she was receiving.
Her devastated family say she "lost her life because she didn’t receive the care to which she was entitled".
They also hit out at a lack of eating disorder services in Kent, which meant Hayley had to be treated 120 miles away from her Canterbury home.
At the conclusion of the jury inquest at the Shepway Centre in Maidstone yesterday, Coroner Catherine Wood said she would issue a Prevention of Future Deaths report about the sharing of information.
Hayley had battled a severe form of anorexia for 15 years - since the age of just 12 - and weighed less than four stone at the time of her death in 2019.
She had been repeatedly admitted to hospital since 2015, including a stint in a psychiatric hospital in Beckenham in 2019 while severely underweight.
With no suitable eating disorder clinics in Kent, she was sent from there to The White House rehabilitation unit in Ipswich - a 240-mile round-trip from her Canterbury home, making visiting "almost impossible" for her family.
She was there under a community treatment order, which meant she could have been sent back to hospital if she failed to comply with conditions set by her Canterbury-based clinician.
Six days before her death, she was granted home leave from the unit. But when she returned home to Heath Close in Sturry on December 22, her family were shocked by how unwell she looked.
The following day, they called an ambulance after she collapsed with low blood sugar. She was given glucose by paramedics, but refused to be taken to hospital and was deemed capable of making that decision.
Then on Christmas Eve, she was taken to A&E at the QEQM in Margate after her condition deteriorated, but decided to return home.
Medics again believed she had the capacity to make that decision.
But the inquest was told neither the paramedic nor the A&E nurse who treated Hayley were aware of the community treatment order she was under, and may have acted differently if they were.
Hayley's family found her unconscious in bed on Christmas Day and an ambulance was called. She went into cardiac arrest twice, depriving her of oxygen and causing brain damage.
She was taken to the QEQM, where she died four days later.
The inquest heard from independent expert Dr Tyrone Glover, who said that despite appearances, Hayley did not have the capacity to make decisions about her treatment due to the severity of her illness.
This was known by the team who treated Hayley before she was moved to The White House but there were failures of communication between all agencies, the inquest was told.
The jury concluded a series of failures contributed to Hayley's death, including blood tests not being performed, and a lack of communication between NHS teams in Canterbury and at The White House.
They found Hayley’s family were given "inadequate and insufficient" information to help them support Hayley during her home leave over Christmas, including no guidance about what to do in an emergency, or contact details for her home treatment team.
Hayley's mother Ann Smith said the family had disagreed with a decision to release Hayley from hospital and into community care.
"To make matters worse, Hayley was put into a rehabilitation unit 120 miles away where we were unable to give her the family support she needed," she said.
"While she was at the unit she didn’t receive the care and support that she needed, and when she was sent home for Christmas her condition was so low that we feel that without the expert help she needed, she was in a desperate state. We feel that our Hayley lost her life because she didn’t receive the care to which she was entitled."
Leigh Day solicitor Yvonne Kestler, who represented the Smith family, added: “Hayley’s family did their absolute best to support her through all the years she suffered anorexia nervosa, a recognised mental health condition.
"When Hayley was transferred to the White House she was already considered 'high risk'. That is why it was essential that her community treatment order was complied with. More steps should have been taken when Hayley failed to comply."
Jodie Anderson, senior caseworker at the charity INQUEST, added: "Yet again this is a case where the needs of a young woman in crisis were completely ignored.
"Hayley’s family had every right to expect that she should be kept safe by health professionals, and be returned home when it was appropriate. Yet it was obvious to them just how ill she was when she got there.
“Specialist care for people with eating disorders is too often failing to meet their needs. It is frequently far from home and does not provide adequate support. Eating disorders have the highest mortality rate of any mental illnesses. We must see more action in response to this case to ensure other women and people with eating disorders are better protected."