A decision not to "urgently" refer an anorexic woman whose condition had significantly deteriorated contributed to her death, a coroner said.
Amanda Bowles, 45, was found at her Cambridge home in September 2017.
An eating disorder psychiatrist who assessed her on 24 August apologised to Ms Bowles' family for not organising an admission under the Mental Health Act.
Assistant coroner Sean Horstead said the decision not to arrange an assessment "contributed to her death".
Mr Horstead told an inquest at Huntingdon Racecourse that also on the balance of probabilities the "decision not to significantly increase the level of in-person monitoring" following 24 August "contributed to the death".
In his narrative conclusion, Mr Horstead said it was "possible... that had a robust system for monitoring Ms Bowles in the months preceding her death been in place, then the deterioration in her physical and mental health may have been detected earlier" and led to an earlier referral to the Adult Eating Disorder Service.
He said this absence "was the direct consequence of the lack of formally commissioned monitoring in either primary or secondary care for eating disorder patients".
Source: BBC News, 17 September 2020
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