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Student with anorexia ‘failed by every NHS body that cared for her’, says ombudsman

Report on death of Averil Hart ‘should be a wake-up call to health leaders’ to make urgent improvements to adult eating disorder services
Practice nurse eating disorder

The death of a teenage girl from anorexia could have been prevented had the NHS provided appropriate care and treatment, according to a damning report from the health service ombudsman.

Averil Hart was 19 when she died on 15 December 2012, following a series of failures involving every NHS organisation that should have cared for her, the report says.

A parliamentary and health service ombudsman investigation found missed opportunities and inadequate coordination and planning of Averils care during a vulnerable time in her life, when she was leaving home to go to university. There were also failures in her care and treatment at two acute trusts when she became seriously ill.

The local investigation into her death was wholly inadequate, the report adds, with organisations acting defensively and protectively, rather than taking responsibility.

The ombudsman warns that there are widespread problems with adult eating disorder services

The death of a teenage girl from anorexia could have been prevented had the NHS provided appropriate care and treatment, according to a damning report from the health service ombudsman.

Averil Hart was 19 when she died on 15 December 2012, following a series of failures involving every NHS organisation that should have cared for her, the report says.

A parliamentary and health service ombudsman investigation found missed opportunities and inadequate coordination and planning of Averil’s care during a vulnerable time in her life, when she was leaving home to go to university. There were also failures in her care and treatment at two acute trusts when she became seriously ill.

The local investigation into her death was ‘wholly inadequate’, the report adds, with organisations acting defensively and protectively, rather than taking responsibility.

The ombudsman warns that there are widespread problems with adult eating disorder services in the NHS. The report highlights five areas of focus for improvement:

  1. Training on eating disorders for all junior doctors, to improve understanding of these complex mental health conditions.
  2. Greater provision of eating disorder specialists.
  3. Adult eating disorder services achieving parity of provision with child and adolescent services.
  4. Better coordination of care between NHS organisations treating people with eating disorders.
  5. National support for local NHS organisations to conduct and learn from serious incident investigations, particularly in circumstances involving several organisations.

‘Not unique’

Bill Kirkup, who led the ombudsman’s investigation into Averil’s death, said: ‘Nothing can make up for what happened to Averil and her family. 

‘I hope this report will act as a wake-up call to the NHS and health leaders to make urgent improvements to services for eating disorders so that we can avoid similar tragedies in the future.’

Ombudsman Rob Behrens said: ‘Averil’s tragic death would have been avoided if the NHS had cared for her appropriately.

‘Sadly, these failures, and her family’s subsequent fight to get answers, are not unique.

‘I hope that our recommendations will mean that no other family will go through the same ordeal.’

All the organisations involved have apologised publicly and offered condolences to Averil’s family.

New processes for high-risk patients

An NHS Midlands and East spokesperson said ‘real progress’ was being made in expanding eating disorder services in England and said: ‘The NHS apologises again for these terrible events.’

Cambridgeshire and Peterborough NHS Foundation Trust chief executive Tracy Dowling said the trust would review the ombudsman findings and support its recommendations. 

She said: ‘Since Averil’s death we have implemented a number of new guidelines and processes for managing high-risk patients with eating disorders to ensure all lessons continue to be learned.’

A spokesperson for the Norfolk and Norwich University Hospitals NHS Foundation Trust said the organisation had met Averil’s family in 2014.

‘Since then we have taken into account the learning from this tragic event and our structure and processes have been reviewed. Across the trust, there is greater awareness and recognition of the issues associated with eating disorders.’

The North Norfolk Clinical Commissioning Group said it would take forward the ombudsman recommendations.

Failures and ‘missed opportunities’
  • By 2011, Averil had a three-year history of anorexia nervosa and a very low body mass index, indicating significant risk to her physical health.
  • She was admitted to the eating disorders unit in Cambridge in September 2011 and spent the following 11 months as an inpatient.
  • In August 2012, doctors decided she could be discharged to take up a university place in Norwich, and she was referred to outpatient eating disorder services in Norfolk for ongoing treatment. She was not allocated a care coordinator until October.
  • University GPs were asked to monitor her condition weekly, but on Averil’s third visit in early November a locum GP told her she did not need to come back for a month.
  • At the end of that month, Averil’s father and sister visited her and – shocked by how much weight she had lost – made an emergency call to the eating disorders unit in Cambridge. A medical review was organised for 7 December.
  • Averil was found having collapsed in her university room on 7 December. She was taken by ambulance to the emergency department at the Norfolk and Norwich University Hospitals NHS Foundation Trust, where she spent three days.
  • On 11 December, Averil was transferred to the Cambridgeshire and Peterborough NHS Foundation Trust. Overnight her blood sugar fell to a very low level.
  • She did not receive appropriate treatment for this and became unconscious. She suffered brain damage due to low blood sugar levels and died in hospital the next day.

 


Further information

Read the ombudsman’s full report into Averil Hart’s death


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