A 20-year-old woman weighed 3½ stone when she died from complications arising from severe anorexia nervosa, the Dublin City Coroner's Court was told yesterday.
Ms Lynne Godfrey, of Carnlough Road, Cabra, Dublin, had attended a private therapy centre which specialises in eating disorders, the Marino Therapy Centre, for treatment which began in March 2002.
She was admitted to Beaumont Hospital at the end of August when her condition deteriorated. She was discharged, but readmitted again only days later.
She died on September 6th, 2002.
A consultant gastroenterologist at Beaumont, Dr Frank Murray, said in his deposition to the inquest: "On examination, she was the most profoundly malnourished patient I had ever seen."
The Dublin City Coroner, Dr Brian Farrell, stated: "There must be serious concerns as to why that should be."
Dr Farrell said death was due to complications arising from severe anorexia nervosa.
The coroner read evidence from the previous hearing.
Ms Godfrey's mother, Mrs Jennifer Godfrey, said at Christmas 2001, her daughter was not acting like herself; she was low.
She was not aware then that Ms Godfrey was suffering from anorexia. She took her to the GP and counsellors, and then heard about the centre.
Dr Liam Power, a GP, said he had seen Ms Godfrey in August 2001, when she was suffering from depression and anxiety.
He prescribed a drug, and said she should return in two weeks, but she did not return until January 2002. She then weighed 7st 3 lb.
He wanted to refer her to St Vincent's Hospital, which has an eating disorder clinic, but she refused.
Mrs Godfrey told him that her daughter was attending the Marino Therapy Centre for anorexia, and also a GP who worked with the centre, Dr Tariq Zourob.
Dr Power saw Ms Godfrey again on July 15th, when she weighed 5st 7lb.
He said he made an appointment for her to see a consultant psychiatrist at St Vincent's who specialised in eating disorders, but she was adamant she would not go to hospital.
The founder and clinical director of the Marino Therapy Centre, Ms Marie Campion, said Ms Godfrey first attended on April 10th, and was seen by a psychotherapist.
"Dr Zourob has a GP practice. I always work with him as I'm not medically qualified," Ms Campion said.
From April 10th until May 14th, Ms Godfrey attended six times. The family took her on holiday on May 18th, and she did not return to the centre until June 12th.
"When she came she had deteriorated physically. We recommended more intensive therapy treatment. She was also attended by Dr Zourob," she said.
Ms Godfrey attended the centre every week.
Dr Zourob went on holiday on August 18th, and when he returned on August 30th, they brought Ms Godfrey to the A&E at Beaumont.
"I brought Lynne and her mother to hospital. Eventually Lynne agreed to stay overnight," she said.
At 6 p.m. or 7 p.m., the doctors said she could go home.
On Tuesday, September 3rd, Dr Zourob rang and was very worried. They brought Ms Godfrey with her mother to the hospital at 11 p.m.
Prof Shane O'Neill, of Beaumont, said he saw Ms Godfrey on September 3rd.
She was vomiting, had abdominal pain, was very weak and unable to walk. She weighed 3½ stone.
Ms Godfrey was reviewed on September 5th by Dr Murray, who said she had very advanced and profound anorexia nervosa and advanced malnutrition.
Early the next morning, Ms Godfrey went into cardiac arrest and resuscitation attempts were unsuccessful.