The heartbroken father of a young woman who died after battling an eating disorder said he hopes a coroner’s recommendations to improve services and spare other families the same grief is “Jenni’s legacy”.

Nursing graduate and advanced biomedical science student Jennifer Michelle Matters, known as Jenni, was a high achieving, “bright, thoughtful” woman who loved spending time with her loved ones.

Jenni struggled with anorexia nervosa for two years, and sought help from her GP, psychologist, psychiatrist and dietitian following her diagnosis in 2019, along with multiple hospital admissions.

But in May 2021, Jenni, then 24 years old, ended her life. She weighed less than 30kg.

An inquest was heard to examine the services provided to Jenni during her fight with anorexia nervosa, including the operation of the Statewide Eating Disorder Service (SEDS), which is a unit within the Flinders Medical Centre.

In her findings, State Coroner Naomi Kereru said Ms Matters sent a text message to her psychologist during an admission in 2019 which read: “The nurses are USELESS – one asked me how often do you eat because my Keto Diet isn’t working and I need to lose weight”.

“She also told (the psychologist) that another staff member had said to her, ‘no offence but you don’t look anorexic’, which is an especially concerning comment to a patient whose self-perception was already skewed to feeling overweight,” Ms Kereru said.

“These comments were absolutely inappropriate.”

In a letter to a psychiatrist before her death, Jenni wrote that she was not here to blame her death on anyone but if things had been different she may not have been put “so off-side” by treatment initially.

“I don’t know what more, if anything, could have been done in my case,” she wrote.

“More than likely nothing, but I just needed to write down the fact that I am dying and so desperately completely exhausted from fighting and if treatment looked a tiny bit different I may not have walked the same path.”

The inquest heard that there was a gap in treatment for all patients with eating disorders, but that having a BMI of under 15 further limited the options available.

Ms Kereru said there was a plan for a new Residential Eating Disorder Service (REDS) at the Repat, which will comprise a five-bed residential centre providing specialist clinical care.

Ms Kereru made several recommendations, including that SA Health review the adequacy of the number of the beds in SEDS and the new proposed REDS to determine whether additional beds are needed and how that can be achieved.

She also recommended that consideration be given to establishing an acute inpatient ward that is specifically set up for treating patients with eating disorders who require medical stabilisation.

“Given the evidence I heard, I am satisfied that there is a need for increased education among medical and nursing staff in relation to eating disorders and in particular about the language that is appropriate when engaging with these patients,” Ms Kereru said.

However, Ms Kereru said that given recovery with SEDS treatment is more often unsuccessful than it is successful she was unable to conclude it would have prevented Jenni’s death.

“In my view, the only chance of preventing Ms Matters’ death would have been if there was a service that operated to provide acute inpatient eating disorder treatments to patients with dangerously low BMIs, as I have recommended should be implemented above,” she said.

Outside court, Jenni’s father, Shaun Matters told media that the difference between services for anorexia and other deadly diseases, such as cancer was like “chalk and cheese”.

“The recommendations that the coroner has made I sincerely hope are implemented by the state government,” he said.

“There were some pivotal moments that would have greatly assisted in Jenni’s treatment.

“Nothing brings our daughter back. We live with that pain everyday.

“If the coroner’s recommendations spare that grief for other families that’s Jenni’s legacy.

“I can’t say that the death would have been preventable but she should have been given more of a fighting chance.”