Anorexic woman's death 'would have been prevented' with better treatment
A woman who died as a result of anorexia "would have survived" had she received better treatment, a report has said.
The assessment of Charlotte Robins' mental state was "fundamentally flawed", according to a report from the Parliamentary Ombudsman.
She died in 2010 aged 29, weighing 3st 1lbs (20Kg) according to a post-mortem.
The Devon Partnership Trust has apologised for the way it originally investigated the incident.
Ms Robins' parents have been pursuing complaints about the way their daughter was treated for the last six years of her life.
The Parliamentary Ombudsman report said Ms Robins' death from cardiac arrest due to low potassium levels "could have been avoided if she had received different care and treatment", after she was admitted to Torbay hospital in May 2010.
Ms Robins' family say she developed anorexia with bulimia as a teenager after a ballet teacher told her she looked fat.
When her weight and BMI dropped she was voluntarily admitted to hospital on 27 May 2010.
She was transferred to a psychiatric ward before being discharged on 18 June, when doctors decided she was well enough to make her own decisions about her care and treatment.
She had a home support service which included weekly weight and blood tests with her GP, as well as support from a community carer and psychologist.
However, she cancelled this arrangement shortly after arriving home, and started vomiting regularly.
Ms Robins' father Andrew said: "They allowed her out... and they thought this would be OK, and it was not."
The events leading up to Charlotte Robins' death
27 May 2010 - Ms Robins' agrees to be voluntarily admitted to Allerton Ward at Torbay Hospital.
3 June 2010 - A psychiatrist decides she has the capacity to make her own decisions about her medical care.
9 June 2010 - Ms Robins agrees to be transferred to a psychiatric ward at Torbay Hospital.
18 June 2010 - She is discharged from hospital, with weekly weight and blood tests from her GP, and support from a care coordinator and clinical psychologist.
25 June 2010 - Having cancelled her home support service, Ms Robins attends a prearranged appointment with her consultant psychologist with her mother and care co-ordinator.
28 June 2010 - Ms Robins dies at Torbay Hospital, weighing just 3st 1lbs (20Kg).
The report said the assessment that decided Ms Robins had the mental capacity to be in control of her own care was "fundamentally flawed", and did not take into account her "powerful anorexic compulsions".
It added that those flaws led to her being discharged from hospital with minimal support "when this was not appropriate", and either detention in hospital or closer home supervision "would have kept Charlotte safe".
Experts asked to review the case told the Ombudsman that if she had been in hospital or under appropriate supervision, her potassium levels would have been monitored, and corrected and it is "more likely than not that she would not have developed the arrhythmia which led to her cardiac arrest".
The report said they concluded that "in short, her death at that time would have been prevented".
A spokesman for Devon Partnership NHS Trust said: "We apologise for the shortcomings in the way that we originally investigated the incident and communicated with the family.
"We have, however, made a number of important changes to our systems, processes and services.
"We know that a dedicated community eating disorders service would bring much-needed specialist help and support to many people across Devon. We have raised the issue with our commissioners and are discussing it with them."