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Teenager died following failings by agencies to deal with her anorexia

A coroner has found that multiple failings in the care of a teenager with anorexia were probably causative of her death

Posted on 06 November 2020

A coroner has delivered his conclusion following an inquest into the death of student Averil Hart, who suffered anorexia and died aged 19, in December 2012, six days after she was found collapsed on the floor of her university flat.

Coroner Sean Horstead said Averil died after she was inappropriately assigned to a trainee psychologist without appropriate training. In a narrative verdict, in which the coroner said a number of failures were ‘probably causative’ to Averil’s death, he found that her father was not consulted as to his concerns with the Norfolk Community Eating Disorder Service.

The coroner also found that there was a gross failure by Norfolk & Norwich University Hospital to plan or provide nutrition for Averil, with no dietician or appropriate psychiatric support for her over the weekend, which resulted in a failure to manage her anorexic behaviour.

After Averil was found collapsed at her University of East Anglia flat, she was taken to hospital, but it took a further three days for the local eating disorder specialist to attend. Her condition deteriorated and she was transferred to Addenbrooke’s Hospital in Cambridge where she died three days later. Averil’s family has had to wait seven years for the inquest to take place.

In that time there has been a lengthy investigation by the ombudsman and calls for the urgent reform of the NHS eating disorder services. Inquests have already been held into the Cambridgeshire deaths in 2017 and 2018 of four other women who suffered eating disorders.

The ombudsman’s 2017 report, Ignoring the alarms: How NHS eating disorder services are failing patients, concluded that every NHS organisation involved in Averil’s care had failed in some way. It made five recommendations relating to the improvement of treatment for eating disorders nationwide but a Commons report, published 18 months later, said insufficient progress had been made.

Now Mr Horstead is expected to write a prevention of future deaths report calling for urgent changes to eating disorder services nationwide.

Following the inquest, Averil’s father, Nic Hart said: “It has taken Averil’s family seven years to finally receive a formal inquest into her tragic death.

“During those seven years, other patients have died needlessly, largely due to the poor quality of the three-and-a-half-year investigation by the Ombudsman (PHSO), but also due to the lack of open and honest disclosure by the NHS trusts who were responsible for Averil’s care.

“We hope, now that the Coroner has finally looked in detail at the evidence of the failings by each and every organisation looking after Averil, that there will be recognition of the urgent need for reform of the NHS eating disorder services not just in the east of England, but Nationally, involving training and more resources.

“Averil’s case has highlighted the desperate need for open and honest disclosure when things go wrong, so that other patients do not suffer in the same way. Without this honesty and a proper independent investigation, we risk a recurrence of the major NHS incidents such as Mid Staff’s, Southern Healthcare, East Kent and others.

“As the Cambridge Coroner originally indicated, Averil’s case is inextricably linked to at least four other cases of patients being cared for by Cambridge and Peterborough Foundation Trust. Our hearts go out to the other families who have lost loved ones in similar circumstances.

“The sadness of losing Averil will always be with us, but we hope that the Secretary of State for Health will ensure that the changes proposed by NHS England and NHS Improvement are implemented immediately. This will help to to save lives and prevent other families having to suffer what we have suffered.

"The change to truly independent external investigations of patient deaths is now self-evident across the NHS, not just for patients with Eating Disorders but for serious incidents involving all patients."

Leigh Day partner Emma Jones, who represents the family, said:

“We have been impressed with the coroner’s approach to the investigations into tragic loss of life in respect of five eating disorder deaths.

“In Averil’s case the coroner held a full and open investigation hearing from many witnesses and calling for expert evidence. We could not have asked for any more from the coroner and we welcome his conclusion.

“It has been made clear that there were many missed opportunities and a number of agencies who simply didn’t do what needed to be done. It is rare for an inquest involving medical care for a patient not in detention to engage Article 2. The fact that the coroner agreed that Article 2 applied to this Inquest demonstrates the seriousness of the failings. The coroner’s summing up, reasons and conclusions make for haunting reading.

“An issue that has caused us great concern was oral evidence from clinicians that was in direct contrast to witness statements provided to the coroner. Some of the statements were based on correspondence from 2014 in which it was set out that Averil’s food intake whilst at NNUH was monitored closely, when in fact there were no monitoring charts.

“The statements also emphasised the importance of ensuring immediate liaison with a mental health professional. However, the evidence we heard suggested that guidance was not given and there would have been no mental health support available from admission on the Friday evening until Monday morning.

“This must now be addressed either by way of considering whether there is a case to answer in relation to the duty of candour or any other legal route."