Inquest into the death of Chloe Grace Tupper
Delivered on : 13 November 2024
Delivered at : Perth
Finding of : Deputy State Coroner Linton
Recommendations :
Recommendation 1: I recommend that the Department of Health continue to collect hospital-based eating disorders data and the Mental Health Commission undertake demand modelling to support future state-wide investment. Further to this, I recommend the Mental Health Commission undertake regular benchmarking of WA youth and adults with eating disorders against National trends and data.
Recommendation 2: I recommend that the Mental Health Commission consider developing a working group to explore unmet needs for people with chronic and complex or severe and enduring eating disorders to ensure that evidence-based programs are offered and primary care providers are supported in managing the high level of risk associated with this cohort. The working group should give specific consideration to how best to transition care from child specialist services to adult services (recognising crossover of care is likely for patients with severe and enduring eating disorders), in order to ensure good continuity of care.
Orders/Rules : N/A
Suppression Order : N/A
Summary : On 9 June 2024, Chloe Tupper died at Joondalup Health Campus. The cause of death was organ failure due to anorexia nervosa. Chloe was an involuntary patient under the Mental Health Act at the time of her death, so an inquest was mandatory.
The inquest hearing explored Chloe’s medical care from the early stages of her diagnosis through to her later years of GP only care, leading up to her final hospital admission.
Chloe had a history of severe and enduring anorexia nervosa. She was first diagnosed at 14 years of age. She had a number of hospital admissions over the years, during which she would put on a small amount of weight, but she would then be discharged and quickly lose any of the weight she had gained. Over time, Chloe became increasingly resistant to the concept of being treated by way of re-feeding and she would become actively suicidal. Chloe’s family eventually came to accept that Chloe would not accept being re-fed to a normal weight and they tried to help her to live a comfortable life within the parameters of the weight she was willing to accept.
In 2017, Chloe was discharged by her community mental health service after she stopped engaging and it was determined that further coercive hospital treatment would be of limited beneft. Her medical care from that time was managed solely by her GP. It was generally limited to an assessment of her weight and blood pressure. Her weight was generally stable at around 36 – 37 kg (BMI 12 to 12.5) for a few years. However, in October 2019 Chloe had an admission to Royal Perth Hospital after some changes in her home life, and swelling in her legs, led her to feel suicidal and she took an overdose of prescription medications. Her weight on admission was 30 kg (BMI 10), indicating she had experienced a dramatic fall from her previous relatively stable weight. Chloe received treatment for the overdose and complications related to her low body weight. The option of re-feeding was explored, but a comprehensive psychiatric assessment found that Chloe was at high risk of suicide if that was attempted. After significant consultation with Chloe and her family, as well as various health practitioners and hospital management, a decision was made that Chloe would be discharged home on the understanding that she declined further treatment and that her illness was to effectively be treated as terminal. However, there was no referral to a community palliative care team.
Chloe remained living at home with her family, seeing her GP intermittently, until 2 June 2020. On that day, Chloe fell and was unable to get up. Her family called her GP practice and they recommended that the family call an ambulance. Chloe was taken by ambulance to Joondalup Health Campus, where she was admitted to the High Dependency Ward due to serious medical complications of her illness. A psychiatric assessment was undertaken and Chloe was made an involuntary patient under the Mental Health Act as she was not considered to have capacity to make treatment decisions due to her malnourished state. She was given supportive treatment, but no active re-feeding, while further consultation was undertaken in order to make a decision about the type and level of medical care that Chloe should receive. Chloe and her parents made it very clear they did not want Chloe to be forced to undergo active treatment and they had made their peace that Chloe would soon die from complications of her anorexia nervosa. Other psychiatrists and an eating disorder specialist were consulted and there was a plan to bring Chloe’s case urgently before the Mental Health Tribunal.
However, before this could occur, Chloe’s physical condition deteriorated to the point that she was assessed as in severe organ dysfunction without significant chance of recovery. It was established that Chloe was in the end stage of her illness and her condition had deteriorated to the point where comfort case was the only appropriate course. She was commenced on comfort care on 9 June 2020 and she died later that day in the presence of her family. Her treating psychiatrist was not present at the hospital that day and it seems that generally psychiatry was not requested to consider revocation of the involuntary patient order, so Chloe remained an involuntary patient at the time of her death.
The inquest explored recent changes to treatment for eating disorders in Western Australia.
The Coroner found that the death occurred by way of natural causes. The Coroner did not make any recommendations.
Catch Words : Mandatory Inquest : Community Treatment Order : Eating Disorder : Psychiatric Care : Natural Causes
Last updated: 17 December 2024