The death of Louise Cooper on 16/05/20 at her home address was reported to me and I opened an investigation, which concluded by way of an inquest held on 17th December 2021. I determined that the medical cause of Ms. Cooper's death was 1 a Severe Malnourishment In box 3 of the Record of Inquest I recorded as follows: Louise Cooper had been diagnosed with Anorexia Nervosa for many years. She has received care for this condition during a number of in-patient admissions, the last of which ended in July 2019. Over subsequent months she continued to receive care from an eating disorder service until she was discharged on 2 January 2020. Louise knew that the Clinical Psychologist with whom she had worked for a number of years was due to go on maternity leave. She did not wish to work with any other members of the Eating Disorder Service [EDS] team. When discharged her Body Mass Index [BMI] is estimated to have been at a significantly low level of 12.5. She was discharged on the understanding that she would receive ongoing monitoring from her General Practitioner. The GP surgery was notified about the discharge but due to an administrative issue the need for Louise to be monitored was not appreciated. She did not receive the necessary monitoring. During the weeks preceding Louise's death, her health went into further decline. This was in part contributed to by the Coronavirus pandemic in March 2020 which left her more isolated. Having last exchanged text messages with Louise on the 15th May 2020, a friend attended her home address at approximately 12:30pm on the 16th May 2020 to deliver some shopping as previously arranged. Unable to obtain a reply he forced entry and he found Louise to be deceased on her bed in the rear bedroom. A subsequent post mortem examination confirmed she had died from the consequences of severe malnourishment. The conclusion of the Coroner was a Narrative Conclusion as follows: Having been discharged from an eating disorder service on 2nd January 2020, Louise Cooper's condition had not been monitored by medical professionals by the time she died on 16th May 2020 as a result of complications of her previously diagnosed anorexia nervosa.

In addition to the contents of section 3 above, the following is of note:
• Louise was known to have suffered with anorexia nervosa for many years. During the weeks preceding Louise's death, those close to her report a decline in her health.
• It is reported that she stated to friends that the nationwide lockdown due to the Covid-19 Pandemic had removed all of the mechanisms that she had for coping with her condition. A Trust review would later find that as Louise was self­ isolating due to Covid - 19, this may have impacted upon her mental and physical wellbeing due to reduced social contacts.
• Louise did not received the monitoring she was expected to receive during 2020. The court found that had she received that monitoring as envisaged, there was a good chance she would not have died when she did, but was unable to say that she would have survived

Louise Cooper had been diagnosed with Anorexia Nervosa for many years. She has received care for this condition during a number of in-patient admissions, the last of which ended in July 2019. Over subsequent months she continued to receive care from an eating disorder service until she was discharged on 2 January 2020. Louise knew that the Clinical Psychologist with whom she had worked for a number of years was due to go on maternity leave. She did not wish to work with any other members of the Eating Disorder Service [EDS] team. When discharged her Body Mass Index [BMI] is estimated to have been at a significantly low level of 12.5. She was discharged on the understanding that she would receive ongoing monitoring from her General Practitioner. The GP surgery was notified about the discharge but due to an administrative issue the need for Louise to be monitored was not appreciated. She did not receive the necessary monitoring. During the weeks preceding Louise's death, her health went into further decline. This was in part contributed to by the Coronavirus pandemic in March 2020 which left her more isolated. Having last exchanged text messages with Louise on the 15th May 2020, a friend attended her home address at approximately 12:30pm on the 16th May 2020 to deliver some shopping as previously arranged. Unable to obtain a reply he forced entry and he found Louise to be deceased on her bed in the rear bedroom. A subsequent post mortem examination confirmed she had died from the consequences of severe malnourishment. The conclusion of the Coroner was a Narrative Conclusion as follows: Having been discharged from an eating disorder service on 2nd January 2020, Louise Cooper's condition had not been monitored by medical professionals by the time she died on 16th May 2020 as a result of complications of her previously diagnosed anorexia nervosa.