Inquest into the death of Chloe Grace Tupper

AI-generated summary

Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasting improvement. Clinically, the case illustrates key failures: premature discharge at subtherapeutic BMI (12 rather than 18-20) early in her illness, which established a false belief she was untreatable; lack of coordinated transition from paediatric to adult services; absence of a robust statewide eating disorder service requiring her care to be fragmented across public, private, and primary care settings; and failure to establish advance palliative planning when she presented to Royal Perth Hospital in 2019 at BMI 9.7. Her final GP, Dr H., provided compassionate but unsupported care without access to specialist consultation services. When she collapsed in June 2020, disagreement between RPH (who accepted her wish to die) and JHC (who made her involuntary) caused additional distress. The system failed through chronic underfunding of eating disorders services, lack of specialist expertise outside Hollywood Hospital, poor documentation continuity between services, and absence of established pathways for managing severe enduring anorexia nervosa. Better outcomes require early intervention with adequate nutritional restoration, continuity of care through transition ages, statewide specialist services, and for intractable cases, timely palliative care planning while patients retain decision-making capacity.

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