Father pleads for eating disorder service reforms after coroner's inquest

The father of a young woman with anorexia nervosa has implored the South Australian government to adopt a coroner's recommendations for improved eating disorder services — to spare other families the same grief of losing a loved one.

Jennifer Matters, known as Jenni to her family, took her own life when she was aged 24 in 2021, two years after the "intelligent young woman" was diagnosed with the disorder.

In findings handed down today, State Coroner Naomi Kereru said after Ms Matters was diagnosed in 2019, the disorder "very quickly took over her life", and despite efforts to seek treatment "she encountered barriers to effective treatment which tragically proved insurmountable".

Outside court, Ms Matters's father Shaun said his daughter's death — and the resulting inquest findings — must lead to change.

"Nothing brings our daughter back, we live with that pain every day," he said.

He described his daughter as a "bright, thoughtful person" who "wanted to help people" and said there were "some pivotal moments that would have greatly assisted in Jenni's treatment" and given her "more of a fighting chance" to access interventions at the right time.

Mr Matters said the difference between services for anorexia and other deadly diseases, like cancer, were like "chalk and cheese".

"We all understand that if you don't treat cancer it grows and it's harder to get rid of," he said.

"The same with anorexia, if you don't treat it fast, it grows and it becomes more entrenched.

"That's the problem we had with Jenni — the treatment interventions that could have happened much earlier, didn't and that severely hampered her chances of recovery".

Recommendation to establish inpatient ward

Ms Kereru made recommendations to Health Minister Blair Boyer aimed at improving the services available, including setting up an acute inpatient ward specifically to treat "patients with eating disorders who require medical stabilisation to alleviate the situation where these patients are treated in a regular ward that is not therapeutic for, and may even exacerbate, their eating disorder".

During the inquest, the court heard unidentified staff had made comments to Ms Matters while she was in hospital — but not in the Statewide Eating Disorder Service (SEDS) unit — including asking for "diet tips", which Ms Kereru said were "absolutely inappropriate".

"Their nature undermines the therapeutic situation that all health care workers should bring to patients with all manner of conditions," she said.

Ms Kereru also recommended reviewing the adequacy of the number of beds at SEDS — a unit embedded within the Flinders Medical Centre which has six beds for inpatients and "determine whether additional beds were needed".

She said the waitlist for a bed in the inpatient facility "can be up to many months", and that patients could still expect a "significant waiting list" even after a further five beds planned for the Repat Health Precinct were opened.

She noted that an SA Health representative had told the inquest more than 83,000 South Australians were impacted by eating disorders in 2024, and 259 inpatients with an eating disorder as the principal diagnosis in 2023 and 2024 — but only 71 were treated in a SEDS bed.

"This means that 188 of the inpatient admissions were treated at Flinders for their eating disorder outside of the specialist SEDS inpatient program."

Ms Kereru further recommended SA Health develop a clinical pathway for patients with eating disorders and introduce training for medical and nursing staff about the identification and treatment of eating disorders.

Health Minister Blair Boyer offered his condolences to Ms Matters's family and said he would meet with them.

"We can’t change what has tragically happened in 2021, but we can do more to ensure South Australians with eating disorders receive the appropriate treatment and supports," he said.

He said the state and federal governments would jointly invest in SEDS, and that the new Women's and Children's Hospital would include a dedicated eight-bed ward for patients with eating disorders.