Some articles that we see in the tabloids are unbelievable, some are shocking, but this story is the most repulsive and disturbing, this story is appalling and should be considered the most horrifying of them all and this cowardly government have a lot to answer for.

Averil Hart’s death was an avoidable tragedy and this teenager died following a frightening struggle with anorexia and was let down by every single NHS organisation involved in her care and The Parliamentary and Health Service Ombudsman (PHSO) has warned that the death of Averil Hart aged 19 shows widespread problems with adult eating disorders services in the NHS.

An investigation found poor coordination and planning of the teenager’s care throughout an especially vulnerable time in her life, as she was leaving home to go to university and there were failures in her care and treatment in two important trusts after she became dangerously sick.

Ms Hart, from Sudbury in Suffolk, was voluntarily admitted to the Eating Disorders Unit in Cambridge aged 18 in September 2011 and she had a three-year history of anorexia nervosa and was seriously underweight with a significant risk to her physical well-being.

Over the following 11 months as an inpatient, she gradually increased in weight and doctors determined she could be discharged in August 2012 as she was really enthusiastic in taking up a position at the University of East Anglia.

Still underweight, she was transferred to outpatient eating disorder services in Norfolk for continuing treatment.

Yet she was discovered unconscious on the floor of her student flat by a cleaner merely four months later and transported to Addenbrooke’s Hospital in Cambridge, where her blood sugar was not properly monitored.

She died on December 15, 2012.

The PHSO report stated all the NHS organisations concerned in the teenager’s care and treatment between her release from hospital on August 2, 2012, and her demise neglected her in some way and her deterioration and death were avoidable.

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Most of the NHS organisations which dealt with her father’s complaint failed to respond to his anxieties in a delicate, transparent and effective way and their inquiries were not adequately precise or joined-up. They did not provide Mr Hart with the answers he sought about Averil’s care and treatment.

These shortcomings drove Mr Hart to feel intense disappointment with the NHS organisations and intensified his and his family’s extensive suffering emanating from Averil’s needless death and a local inquiry into Ms Hart’s passing was totally lacking with the organisations being guarded and protective of themselves, rather than taking accountability.

While Ms Hart began her university course in September 2012, she was not allotted a care coordinator until October.

In spite of the fact she was meant to have weekly appointments with a doctor, she saw a GP on three occasions between October 12 and November 8 and at the last appointment, a locum GP told her she did not need to come back for a month.

Mr Hart visited his daughter at the university on November 28 and was startled by how much weight she seemed to have lost and made an emergency call to the Eating Disorders Unit in Cambridge.

On the morning of December 7, Averil was discovered collapsed and taken by ambulance to A&E where she saw no specialist eating disorders clinician for three days following admission, by which time her health had depreciated more.

Nursing care was further said to be inadequate and neglected to monitor her health efficiently and The Norwich Acute Trust’s actions fell considerably short of what should have happened and constituted service failure.

This was another missed chance to intervene to stop yet the additional decline in her health, decline that ended in her demise and she was then transported to Addenbrooke’s Hospital on December 11.

Overnight her blood sugar dropped to really low levels, but she did not get suitable treatment for this and became unconscious and sustained brain damage and she died three days later.

Cambridge Acute Trust’s actions fell considerably short of what should have happened and constituted service failure.

This was the ultimate failure that led quickly to Averil’s passing, but it was the last of a long string of bungled chances to see her worsening health and intervene to avert the necessity for her ultimate hospital admission as an acutely ill medical emergency.

The death of Averil Hart was an avoidable tragedy and every NHS organisation involved in her care missed vital chances to prevent the tragedy unfolding at each stage of her illness from August 2012 to her passing on December 15, 2012.

The following replies to Averil’s family were inept and served simply to intensify their suffering and the NHS must learn from these mistakes, for the interest of future patients.

The report calls for junior doctors to be trained about eating disorders as well as the greater provision of eating disorder specialists and greater coordination of care among NHS organisations treating people with eating disorders.

The Ombudsman further called for adult eating disorder services to gain parity with child and adolescent services.

Nothing can make up for what happened to Averil and her family but let’s trust this report will serve as a wake-up call to the NHS and health administrators to make the necessary reforms to services for eating disorders so that they can circumvent comparable failures in the future.

Averil’s shocking death could have been circumvented if the NHS had cared for her properly but sadly, these failures, and her family’s subsequent struggle to get answers, are not unique and the families who brought their complaints forward have helped uncover pressing concerns that need urgent national attention, so hopefully no other family will go through the same tribulation.

Other examples of cases were further supplied in the report, including that of a woman with suicidal thoughts who was inappropriately released from a hospital with an unsatisfactory care plan in place, and died from a heart attack precipitated by starvation.

Another seriously ill woman with a history of being sick and binge eating died of heart failure after taking an overdose following a catalogue of errors by the NHS, including inconsistent and unhelpful therapy sessions, the report said.

The PHSO further apologised to Mr Hart itself for taking too long to conclude its inquiry but the report high points the fatal consequences of a lack of medical and psychiatric error when patients with anorexia nervosa leave the protection of a specialist inpatient unit.

When a patient leaves the hospital, they may still be extremely ill and need special care from a dedicated team and patients with eating disorders can show up anywhere in the health system and each doctor should be able to identify the symptoms.

From medical school upwards, eating disorder education for doctors is negligible and it should not be down to pure chance if a trainee doctor gets any practice in treating eating disorders at all.

The case of Averil is tragic, and the Government should take note of this report so that her family and friends know these blunders won’t be made again.













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