THE family of Charlotte Comer said the "NHS failed her" as a special report is made to prevent future deaths.
A coroner overseeing Charlotte Comer's inquest said "gross failings" by Herefordshire and Worcestershire Health and Care NHS Trust contributed to the death of the 30-year-old, from Earls Croome, near Malvern.
Her inquest heard Miss Comer was suffering from Body Dysmorphic Disorder (BDD) - where a person spends a lot of time worrying about their appearance - and struggled with eating disorders and self-harming.
Miss Comer's sister, Mo Knight Evans, said: “We want to make sure a tragedy like this doesn’t happen again to other families with loved ones struggling with BDD.
"Charlotte was more than aware of the significant impact BDD was having on her life.
"Over the years Charlotte diligently researched her symptoms and was convinced she needed a referral for specialist BDD treatment.
"She knew The Priory offered the care and support she needed but the NHS failed her. "The NHS did not refer her to The Priory and crucially, could not properly manage her expectations."
Worcestershire's senior coroner David Reid recorded a verdict that Miss Comer died of an overdose at Worcestershire Royal Hospital on July 20, 2021.
Mr Reid found Miss Comer died as the result of failures by the NHS trust and ordered a rare prevention of future deaths report be completed - such was his concerns.
The coroner said the key factors contributing to her death were the number of care coordinators she had, the trust had not focused on BDD and her loss of hope after being told a referral to The Priory for treatment had been paused.
It emerged in the inquest her referral was paused by a senior clinician as she thought Miss Comer did not meet the criteria for her place to be locally funded.
READ MORE: Family pay tribute to 'wonderful' Charlotte Comer
READ MORE: Inquest finds NHS trust's "gross failures" contributed to woman's death
The clinician had not understood the place would be funded centrally through NHS England so the referral should not have been paused.
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Her sister continued: “Charlotte went to great lengths to tell every single member of every care team she met the extent of her condition and its devastating impact on her life.
"She battled so hard to be understood and get the specialist care she desperately needed.
"But it was not forthcoming.
“One of Charlotte’s last wishes, before she died, was to ‘make a noise’ so others with BDD do not suffer in the same way.”
Ian Dolan, from the trust, said steps had been taken to address the areas the coroner had raised concerns on including offering reassurance the referral funding mistake could not happen now.
The Samaritans can be contacted 24 hours a day, free, on 116123.
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