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Coroner’s reportPrevention of future deaths · 2025-0270

“Charlotte’s mother formed the view that Charlotte was suffering from an eating disorder…”

Dated 2 Jun 2025, from the coroner for Inner North London. Sent to 1 organisation or person.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

Read the full report on judiciary.uk

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The 56-day response deadline

Deadline passed

Replies were due by 28 Jul 2025. A reply may have been sent and not yet published.

Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.

  1. Report dated2 Jun 2025
  2. Deadline28 Jul 2025
  3. Published on judiciary.uk11 Jun 2025
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
University College London Hospitals NHS Foundation TrustNamed in the report as “University College London Hospitals NHS Trust”Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 28 Jul 2025. A reply may have been sent and not yet published.

The coroner’s concerns

Charlotte’s mother formed the view that Charlotte was suffering from an eating disorder and was under the impression that the referral to a UCLH dietitian was made, at least in part, in order to explore this. In fact, Charlotte was never diagnosed with an eating disorder, did not meet the criteria for a referral on this basis and was referred solely for consideration of whether her nutritional status was having an impact on her height. I found no evidence of any link between Charlotte’s eating and her death. However, that might be different for another child. It seems from the evidence I heard that an explanation, perhaps on the website or in correspondence, that the UCLH dietetic service is not a mental health service and does not treating eating disorders, could be helpful.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source
judiciary.uk, Prevention of Future Deaths reports, 2025-0270
Added to Minute Book
8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0

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