Anorexia-sufferer Averil Hart died after multiple failings in NHS care

Averil Hart, 19, who was afflicted with the condition from the lead up to her A-levels at Colchester Royal Grammar School was let down repeatedly by medical professionals.

A report by the Parliamentary and Health Service Ombudsman looked at how NHS services across the country are failing patients with eating disorders.

It examines the case of Averil, who died in 2012 at Addenbrooke’s Hospital, in Cambridge.

Following her death, the tragic girl’s father Nic Hart, from Sudbury, sought answers.

The report sets out how, aged 18, Averil was voluntarily admitted to the Eating Disorders Unit, in Cambridge, with a three-year history of anorexia and severely underweight.

Over the following 11 months she slowly gained weight and was discharged so she could take up a place at the University of East Anglia, in Norwich.

Prior to her move to Norwich, the report said co-ordination between the Cambridge Eating Disorder Unit and Norfolk Community Eating Disorder Service (NCEDS) was “poor”, with gaps in her weight monitoring.

By the end of a month-long delay in allocating a care coordinator, her condition had worsened and when she was first weighed in Norwich she had lost 6kg.

The coordinator, who at this point was the sole point of contact with Averil, had no experience in looking after people with anorexia.

Her condition grew worse throughout November. Responsibility for monitoring her physical health once in Norwich rested with the GPs of the University of East Anglia Medical Centre.

Averil was not seen as often as she should have been, signs of her worsening health were missed and she was not provided with a named GP.

Her father visited her at university at the end of November, immediately recognising how serious her condition had become.

Having raised the alarm, Mr Hart was reassured action would be taken. NCEDS arranged for a medical review on Friday, December 7, but that morning Averil was found collapsed in her room.

She was taken by ambulance to the emergency department of the Norwich Acute Trust, extremely unwell with a low temperature, low blood pressure, low blood glucose and very underweight.

Her condition was life-threatening, but Averil was allowed to walk around the ward and feed herself from a trolley, so her food intake was unknown.

She saw no specialist eating disorder clinician for three days and her condition was not monitored effectively.

The report added: “These clear failures of care wasted more time during which the continued further acute deterioration in Averil’s condition remained undetected.

“The Norwich Acute Trust’s actions fell far short of what should have happened and constituted service failure.

“This was another missed opportunity to intervene to prevent yet further deterioration in her condition, deterioration that culminated in her death.”

When her serious state was finally recognised, she was transferred to Addenbrooke’s Hospital, but again she was let down.

She arrived on December 11, but was not seen by a doctor for almost five hours.

When she was seen, no decision was recorded concerning her immediate care and that evening Averil’s blood glucose fell further to a level which was “clearly life-threatening.”

The next morning, following an “unsatisfactory” telephone call between a junior doctor and a consultant, she was found unresponsive.

She had severe brain damage and died at 11pm on December 15, with her family by her side.

Following her death, Mr Hart was frustrated in his attempts to find out what happened.

The report found responses to his complaints were often “defensive” and some information turned out to have been deleted.

Rob Behrens, Parliamentary and Health Service Ombudsman, 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.

“The families who brought their complaints to us have helped uncover serious issues that require urgent national attention - I hope that our recommendations will mean that no other family will go through the same ordeal.”

Trusts: 'We are sorry and we have learnt lessons'

HEALTH bosses have apologised and said “steps were taken” following the tragic death of anorexia-sufferer Averil Hart.

A report carried out by the Parliamentary and Health Service Ombudsman concluded: “The death of Averil Hart was an avoidable tragedy.

“Every NHS organisation involved in her care missed significant opportunities to prevent the tragedy unfolding at every stage of her illness from August 2012 to her death on December 15 2012.

“The subsequent responses to Averil’s family were inadequate and served only to compound their distress.

“The NHS must learn from these events, for the sake of future patients.”

Responding to the findings, Tracy Dowling, Chief Executive of Cambridgeshire and Peterborough NHS Foundation Trust, said: “The death of Averil Hart in 2012 was a tragedy and we would again like to extend our apologies to her family and friends.

“Since her 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.

“We will review the Ombudsman’s findings and we fully support the report’s recommendations around how the funding of eating disorder services, including the recruitment and training of staff, can be improved nationally.

“The treatment of eating disorders is highly challenging and our specialist staff remain committed to providing the very best care to help people overcome their complex conditions.”

A spokesman for Norfolk and Norwich University NHS Foundation Trust added: “We met Averil’s family in 2014 to offer our sincere condolences for their sad and devastating loss.

“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.”

A Cambridge University Hospital spokesman apologised to Averil’s family and said the trust accepted the findings of the report.

He added: “The trust would like to repeat the apologies previously made to Averil Hart’s family and accepts the findings and recommendations in the Ombudsman’s report.

“When Averil was transferred to Addenbrooke’s in December 2012, she was already very unwell but her death, at that time, may have been avoided had failures in her care not taken place.

“A thorough investigation has been carried out, lessons have been learned and a number of changes made.

”We will be writing to Mr Hart to outline the changes which have been made since this tragic event, as recommended by the ombudsman.”