08.12.17
Avoidable death of 19-year-old girl lifts lid on ‘serious national issues’ in NHS care
The death of young woman from anorexia nervosa could have been prevented, a scathing report published today has said.
Averil Hart died in 2012 due to a “series of failures that involved every NHS organisation that should have cared for her,” just 10 weeks after starting university at age 19. Her family then submitted a complaint to the Parliamentary and Health Service Ombudsman (PHSO).
She had been treated for her anorexia in Addenbrookes Hospital for 10 months, before being discharged so that she could begin her studies.
Averil should then have received specialist care from the Norfolk Community Eating Disorder Service and the university medical service throughout her studies. However, this care never materialised.
Anorexia has the highest mortality rate of any psychiatric disorder, from medical complications as well as suicide, and over 725,000 people across the UK are affected by an eating disorder.
Earlier this year, her father, Nic Hart, wrote for NHE about how similar tragedies can be avoided in the future.
The Ombudsman investigation found “inadequate co-ordination and planning of Averil’s care during a particularly vulnerable time in her life,” and failures in her care and treatment in two acute trusts.
It also discovered that the local investigation into Averil’s death was “wholly inadequate,” and described the organisations involved as “defensive and protective of themselves, rather than taking responsibility.”
The report highlighted that conversations with experts suggest widespread problems with adult eating disorder services in the NHS, with other examples including a woman with a history of binging and purging who died of heart failure after a “catalogue of errors by the NHS.”
PHSO, Rob Behrens, concluded that Averil’s death would have been avoided had the NHS cared for her appropriately.
“Sadly, these failures, and her family’s subsequent fight to get answers, are not unique,” he said.
“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.”
Dr. Bill Kirkup, who led the investigation, added: “Nothing can make up for what happened to Averil and her family.
“But 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.”
The report highlights five areas of focus in order to improve eating disorder services.
It has recommended that all junior doctors receive training on eating disorders to improve understanding of the complex mental health conditions, along with a greater provision of eating disorder specialists.
Adult eating disorder services should achieve parity with child and adolescent services, with better co-ordination of care between NHS organisations treating those with eating disorders.
It also said that there should be national support for local NHS organisations to conduct and learn from serious incident investigations.
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