The father of an anorexic teenager has said her death was “synonymous with the ongoing national failings within the NHS” as he criticised an investigation into what went wrong in her care.
Averil Hart, 19, died in December 2012 following a series of failures involving every NHS organisation that cared for her, the Parliamentary and Health Service Ombudsman (PHSO) said as it released a report warning of “widespread problems with adult eating disorders services in the NHS”.
Her father, Nic Hart, said the PHSO had “consistently failed to identify the fundamental causes of Averil’s death”.
Its report, released on Friday, concluded that Miss Hart’s death was an “avoidable tragedy” that would have been prevented had the NHS provided appropriate care and treatment.
Averil Heart’s death from anorexia could have been avoided if she’d had proper care, a report has found (Family handout/PA)
Its investigation found inadequate co-ordination and planning of the teenager’s care during a particularly vulnerable time in her life, as she was leaving home to go to university. There were also failures in her care and treatment in two acute trusts after she became seriously ill.
Mr Hart, from Sudbury, Suffolk, said the investigation had taken “far too long”, resulting in further unnecessary deaths.
“Averil’s death matters to all of us because the tragedy of her death is synonymous with the ongoing national failings within the NHS and also within the investigation process when things go wrong,” he said.
“We lost our beautiful daughter, our friend, and all we want are honest answers.
“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.
“They have not established the facts, ignored evidence, and have relied heavily on the verbal evidence of the clinicians that were supposed to care for Averil, rather than referring to the actual medical and supervision records which reflected the gaps in care.
“Next week, it will be five years since Averil died. Averil’s family have dedicated their time to try to get the truth behind Averil’s tragedy, so that others won’t suffer in the same way.”
Averil Hart, 19, suffered from anorexia for three years before her death (Family handout/PA)
Miss Hart, who achieved five A grades at A-level, had a three-year history of anorexia nervosa when she was admitted to the Eating Disorders Unit in Cambridge aged 18 in September 2011.
Over the following 11 months as an inpatient she slowly gained weight and doctors decided she could be discharged in August 2012 as she was keen to take a place at the University of East Anglia.
Still underweight, she was referred to outpatient eating disorder services in Norfolk for treatment.
She was found unconscious on the floor of her student flat by a cleaner four months later and transferred to Addenbrooke’s Hospital in Cambridge, where her blood sugar was not properly monitored.
She became unconscious and suffered brain damage after her blood sugars dropped to dangerous levels, and died three days later, on December 15 2012, with her family by her side.
The PHSO report said all the NHS organisations involved in the teenager’s care and treatment between her discharge from hospital on August 2 2012 and her death failed her in some way and her “deterioration and death were avoidable”.
Averil Hart just before her death in 2012 (Family handout/PA)
The report said: “Cambridge Acute Trust’s actions fell far short of what should have happened, and constituted service failure.
“This was the final failure that led immediately to Averil’s death, but it was the last of a long series of missed opportunities to recognise her deteriorating condition and intervene to prevent the need for her final hospital admission as an acutely ill medical emergency.”
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.
“The families who brought their complaints to us have helped uncover serious issues that require urgent national attention.”
The PHSO apologised to Mr Hart itself for taking too long to complete its investigation.
Other examples of NHS failures given in the report included that of a woman with a history of vomiting and binge eating, who died of heart failure after taking an overdose following a catalogue of errors by staff, including inconsistent and unhelpful therapy sessions.
The report calls for junior doctors to be trained on eating disorders as well as greater provision of specialists and better co-ordination of care between NHS organisations treating people with eating disorders.
Dr Dasha Nicholls, chairwoman of the Royal College of Psychiatrists’ eating disorders faculty, said: “This report highlights the fatal consequences of a lack of medical and psychiatric oversight when patients with anorexia nervosa leave the safety of a specialist inpatient unit.
“When a patient leaves hospital, they may still be very ill and need specialist care from a dedicated team.”
A Department of Health spokeswoman said: “We are introducing the first ever eating disorder waiting time standards and investing £150 million creating 70 new community eating disorder services across the country, so that no-one will have to go through the same ordeal as Averil.”