A GP surgery did not take the height and weight of a mum-of-two with an eating disorder which meant she was not referred to specialist care, an inquest has heard.

WARNING: This article contains information about an eating disorder which some people may find distressing.

Amy Elizabeth Rowe, of Romford Street, Burnley, died at Royal Blackburn Hospital on March 7, having gone into cardiac arrest because of a bleed on her bowel.

An inquest at Accrington Town Hall, attended by Amy’s sister, Abigail Page, aunt Angela Spencer, and stepfather Alan, heard Amy had been suffering with depression, an eating disorder and overuse of painkillers for several years.

On Sunday, March 6, Amy went out to the shop at about 4.15pm, returning about an hour later.

When she got back, she vomited in the bathroom and shouted to her uncle, Steven Spencer, for help.

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Mr Spencer walked in and found a lot of blood, but Amy was still conscious. He called 999 and an ambulance was sent.

While waiting for the ambulance, Amy lost consciousness and went into cardiac arrest shortly after paramedics arrived.

She was given CPR and taken to Royal Blackburn Hospital where it was discovered she had a bleed in her bowel, however the hospital could not locate if for six hours.

They also took about an hour to find blood for Amy, despite her being able to have blood which was easily accessible.

A conversation was had with Amy’s family as she had gone into multiple organ failure, and she died after a cardiac arrest on Monday, March 7.

Her cause of death was determined to be cardiac arrest due to a gastrointestinal bleed, as a result of an eating disorder and use of anti-inflammatory drugs.

It was said Amy worked well with her GP surgery but she was not responsive with other programmes including the Eating Disorder Service and Mind Matters.

Dr Stephen Hebden, who did not treat Amy, said she was on antidepressants for several months in the lead up to her death.

The GP surgery knew about Amy taking anti-inflammatory drugs, having informed local pharmacies to not sell them to her.

They also knew about her eating disorder for several years, having had previous referrals to services but she did not engage with them.

In 2018, she was taken to A&E on two occasions where she was treated for her eating disorder. She also had a scan to check for ulcers due to the drug use however nothing was found.

Amy attended her GP following the death of her mother in May 2021 and was referred to the Eating Disorder Service, but the GP did not send recent height and weight details for Amy, so the referral was sent back to the GP.

Despite a visit just days after this, the height and weight were never sent to the service, meaning Amy did not receive the help she needed for her eating disorder.

In February 2022, just days before her death, Amy attended her GP practice and saw Dr Mary Adam, telling her she was suffering with vomiting and she was struggling to eat.

The GP organised a blood test, prescribed an anti-sickness medication and ordered a repeat prescription for anti-depressants.

The blood test was not requested as urgent, but Dr Hebden said he cannot say whether Amy told the GP she saw how frequent the vomiting was.

Coroner Laura Nash said despite the ‘missed opportunity’ by the GP of taking Amy’s weight and height, she could not conclude whether the referral would have benefitted Amy due to her previous non-engagement.

Ms Nash provided a narrative conclusion for Amy’s death.

She said: “Amy Rowe died of a cardiac arrest, caused by an upper gastrointestinal bleed which was the result of years of abuse of anti-inflammatory medication, linked to an eating disorder.”