Note: The following text includes emotive topics and personal experiences relating to suicide and eating disorders that some may find difficult to read.

We urgently call for a confidential inquiry into the avoidable deaths of eating disorder patients. Eating disorders are treatable illnesses. They are dangerous and life-threatening when untreated, under-treated, or poorly treated. But this risk to life is preventable, and deaths from eating disorders are not inevitable. 

With integrated, well-resourced and evidence-based treatment recovery is possible, even in the most severe cases and after many years of suffering.

Despite this, coroners, families and communities continue to see too many lives needlessly lost.  This should not be happening. It doesn’t need to be this way.

Zara’s Story

“My beautiful daughter, Zara—intelligent, sassy, kind, and compassionate—took her own life on 22nd September 2021 after struggling with an eating disorder for nearly 10 years.

This should never have happened.

Zara was diagnosed with Anorexia Nervosa in May 2013 and was admitted to an Eating Disorder Unit almost immediately. Instead of being good news for her recovery, this is when the nightmare began. 

From May 2013 to June 2021, Zara endured 13 inpatient admissions across seven different units, including three years as a continuous inpatient—nearly two of which she spent without ever leaving one of the units or going outside. With each admission, her eating disorder and mental health deteriorated further. During this time, she was restrained daily, often by a minimum of six people holding her down. She received very little therapy, and instead, there was a culture of patient blaming and shaming.

In the last two years of her life, Zara was crying out for help, but no one would listen. The Eating Disorder Unit discharged her completely, handing her over to the community mental health team. I spent nearly every day taking ligatures off her, lifting her down from her wardrobe when I found her near unconscious, and performing CPR when I found her in the shower.

There was little to no support from our community psychiatrist: we were left to cope alone. No matter how much we pleaded for help, it was a constant battle, and we never received the support Zara so desperately needed.

My beautiful daughter should never have died from this illness. There was a whole world out there for her, and she had so much to give. But ultimately, Zara felt like everyone had given up on her. She was only 24 when she died, but she was exhausted, and didn’t know any other way to keep going without support."

Zara's story is just one of many, a story that is unfolding for countless others across the country. Behind these tragedies are systemic failures, often overlooked and hidden behind a lack of national data, questionable legal decision-making, and cost-saving agendas. 

In many parts of the UK, the treatments available to patients are not supported by evidence and can even be harmful. Rather than providing integrated and evidence-based care, underfunded services and poorly trained staff often leave high-risk patients institutionalised or without any meaningful or appropriate support. 

The system fails to listen to those who matter most—the patients, and their families and supporters —sometimes fostering a harmful culture of patient-blaming instead of delivering compassionate and individualised care that promotes recovery.

Enough is enough. For too long, those affected by eating disorders have faced neglect and injustice, leading to avoidable deaths and the highest mortality rates among all mental health disorders.

We demand transparency, we demand accountability, and, above all, we demand change to prevent further unnecessary deaths. This can only be achieved by implementing the lessons learned from a confidential inquiry into avoidable deaths.