A depressed woman who became obsessed with checking herself in mirrors and only drank Pepsi Max killed herself after "gross failings" by medics, an inquest heard.
Charlotte Comer, 30, suffered years of mental health battles over her Body Dysmorphic Disorder (BDD) after she was bullied at school and became obsessed with checking her reflection as well as self-harming.
The assistant physiotherapist became anorexic and her body mass index plummeted to 16 - the same as an average four-year-old child, an inquest heard.
Comer, of Earl’s Croome, Worcestershire, consumed a diet of only Pepsi Max but despite her condition, she eventually "lost hope" of receiving help and died from an overdose on 20 July, 2021.
Worcestershire Coroner David Reid said Herefordshire and Worcestershire Health and Care NHS Trust was guilty of "gross failings" which contributed to her suicide.
The inquest heard Comer had a history of overdosing and in 2018 fell into a three-week coma for three weeks after taking pills.
Throughout her struggles, she had eight care coordinators but for five months in 2021 did not see anyone about her condition.
Months before her death, Comer was referred to The Priory Hospital for treatment, the inquest heard, but her referral was paused by a doctor.
In a letter explaining her condition to her GP, Professor Veal, from London’s The Priory Hospital, wrote that with BDD "you are frequently checking reflective surfaces and that’s significantly distressing for you".
Despite her condition, a senior clinician did not feel Comer's conditions met the criteria for her treatment to be locally funded, but they had not realised the care would be fully funded by NHS England and she should have been referred for treatment.
The inquest heard the blunder led Comer to feel "confused" and suffer a "loss of hope".
Liam Dolan, from Herefordshire and Worcestershire Health and Care NHS Trust, said the lack of coordinators was due to sickness and an extensive workload that had seen staff handling 100 cases each.
After the inquest at Stourport-on-Severn, Comer's sister Mo Knight Evans said: "We want to make sure that a tragedy like this doesn’t happen again to other families with loved ones struggling with BDD.
"Charlotte was articulate and intelligent. She was more than aware of the significant impact that 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."
She said her sister had gone to "great lengths" to tell "every single member of every care team" she met the extent of her condition and its impact on her life, but no help or specialist care was forthcoming.
"One of Charlotte’s last wishes, before she died, was to 'make a noise' so that others diagnosed with BDD do not suffer in the same way that unfortunately had," she added.