Father’s questions over death of anorexic student Averil Hart after Ombudsman criticises NHS failings in damning report
The deterioration and death of an anorexia sufferer just 10 weeks into her first term at university was tragic and avoidable, a damning report being laid before Parliament today reveals.
Every single NHS organisation involved in the care of former Colchester Royal Grammar School pupil Averil Hart failed her in some way, according to the findings of a Parliamentary and Health Service Ombudsman (PHSO) investigation.
The 19-year-old collapsed in her flat at the University of East Anglia (UEA) on December 7, 2012.
She was rushed to Norfolk and Norwich Hospital (N&N) with a dangerously low temperature, blood sugar and blood pressure – but she spent three days there before medics realised the seriousness of her illness.
Doctors transferred her to Addenbrooke’s Hospital in Cambridge on December 11 – and although she arrived at 2.40pm, she was not seen for five hours.
She died a few days later on December 15, after suffering a heart attack and severe brain damage from the low blood sugar.
Five years on, the PHSO report into the handling of her care and treatment lays bare a catalogue of failures by the Cambridge and Peterborough Foundation Trust (CPFT), who used to run the Norfolk Community Eating Disorder Service (NCEDS), UEA Medical Centre, Addenbrooke’s and N&N.
The damning document suggests a “very significant” deterioration in Averil’s health went unrecognised, despite her losing weight at an alarming rate.
Ombudsman Rob Behrens CBE wrote: “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 to her death.
“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.”
Although the actions of all four NHS organisations are criticised by the PHSO, Averil’s father Nic, from Sudbury, thinks it does not go far enough.
He said: “Averil’s death matters to all of us because the tragedy is synonymous with the ongoing national failings within the NHS and also within the investigation process when things go wrong.
“Not only was the care that Averil received negligent, but the investigation of her death took far too long and this has resulted in further unnecessary deaths.
“We lost our beautiful daughter, our friend, and all we want are honest answers.
“We want to know, why did our beautiful daughter die?
“Despite our family providing all the key evidence to the PHSO investigation, the Ombudsman has consistently failed to identify the fundamental causes of Averil’s death.
If our questions are not answered, and lessons not learned, more people will die.”
A bright and promising young student, Averil began studying for a degree in English and creative writing at UEA in September 2012, after spending 11 months as at the Eating Disorder Unit in Cambridge, run by CPFT.
Her records were passed to the UEA Medical Centre, where GPs were asked to monitor her condition weekly.
While at university, she had six sessions with her new care coordinator – who had no experience of looking after people with anorexia – and saw a GP three times.
During her last appointment, a locum GP told her not to come back for a month.
On November 28, Averil’s father and sister visited her and were shocked by how much weight she appeared to have lost.
They made an emergency call to the Eating Disorders Unit, and a medical review was arranged with the care coordinator and a speciality doctor for December 7 – but she collapsed that morning.
Averil’s family had serious concerns about her care, and ever since she died, have been fighting for answers.
But the PHSO also found responses to Mr Hart’s requests were delayed and “appeared evasive”.
He said they did not uncover serious failings – adding that their complaint handling was so poor that it was “maladministration”.
The report adds: “Individually, these failures are seriously unsatisfactory.
“Collectively, they paint a consistent picture of unhelpfulness, lack of transparency, individual defensiveness and organisational self-protection that is of great concern.”
Going forward, Nic and Averil’s mother Miranda Campbell, along with the rest of her family, are due to hear when and where their daughter’s inquest will take place.
Now the report is out, a coroner will be able to open proceedings in due course.
Mr Hart hopes this will help to give his family the answers they need.
The NHS organisations mentioned in the Ombudsman’s report have also responded to the findings.
CPFT chief executive Tracy Dowling apologised to Averil’s family and friends on the trust’s behalf.
She added: “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.
“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.”
A N&N spokesman said: “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.”
Representatives for UEA Medical Centre said: “We would wish to reiterate our sincere condolences to the Hart family. We will now be taking the time to read carefully and reflect upon the Ombudsman’s findings.”
A PHSO spokeswoman admitted the investigation took too long to complete.
She added: “We have robust processes in place and our decisions are evidence based.
“There are times when people find it hard to agree with our findings.
“When that happens, we work with them to explain how we’ve reached our decision.”
Representatives for CUH said they accept the findings.
A spokesman added: “When Averil was transferred to Addenbrooke’s 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 from what happened to Averil and a number of changes made.
”We will be writing to Mr Hart to outline the changes, as recommended by the Ombudsman.”
What happens now?
The PHSO is now urging health organisations across the country to take action in the wake of the report into Averil’s treatment.
Four recommendations are listed – the first suggests the General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders.
The second recommends that Health Education England (HEE) reviews how its current education and training can address gaps in provision for eating disorder specialists.
The Ombudsman also wants the Department of Health and NHS England to review the existing quality and availability of adult eating disorder services to achieve parity with child and adolescent services.
And the fourth recommendation asks the National Institute for Clinical Excellence to consider including coordination in its new Quality Standard for eating disorders, to help bring about urgent improvements in the area.
If you have been affected by any of the issues raised, visit BEAT, the UK’s Eating Disorder charity, for help and support.
To view the full report, visit the PHSO website.