Teenager's death from anorexia was 'avoidable' if she had the right NHS care
Averil Hart who died of anorexia two NHS teams failed to care for her a report stated
Picture: UNKNOWN

A teenager’s death from anorexia was an ‘avoidable tragedy’ that would have been prevented with the right NHS care, a damning report has concluded.

Averil Hart, 19, died following a series of failures that involved every NHS organisation that cared for her, the Parliamentary and Health Service Ombudsman (PHSO) said as it warned of ‘widespread problems with adult eating disorders services in the NHS’.

Its investigation found inadequate coordination 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.

Teenager's death from anorexia was 'avoidable' if she had the right NHS care
The NHS was criticised for a catalogue of failures (Picture: Getty)

Ms Hart was voluntarily admitted to the Eating Disorders Unit in Cambridge aged 18 in September 2011.

She had a three-year history of anorexia and was severely underweight.

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 up a place at the University of East Anglia.

Still underweight, she was referred to outpatient eating disorder services in Norfolk for ongoing treatment.

But she was found unconscious on the floor of her student flat by a cleaner just four months later and transferred to Addenbrooke’s Hospital in Cambridge, where her blood sugar was not properly monitored. She died on December 15 2012.

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.

Although Ms Hart was meant to have weekly appointments with a doctor after starting uni, 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 university on November 28 and was shocked by how much weight she appeared to have lost and made an emergency call to the Eating Disorders Unit in Cambridge.

As a result, a medical review with her care coordinator and a speciality doctor from the eating disorder service was organised for December 7.

On the morning of December 7, Averil was found collapsed and taken by ambulance to A&E where she saw no specialist eating disorders clinician for three days after admission, by which time her condition had deteriorated further.

Nursing care was also said to be deficient, and failed to monitor her condition effectively

She was then transferred to Addenbrooke’s Hospital on December 11. Overnight her blood sugar fell to very low levels, but she did not receive appropriate treatment for this and became unconscious and suffered brain damage. She died three days later.

The report said: ‘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.

‘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 from August 2012 to her death on 15 December 2012.

‘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.’

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

The Ombudsman also called for adult eating disorder services to achieve parity with child and adolescent services.

MORE: Suspect caught on camera escaping police car as officers make second arrest

MORE: Olympic gymnast doctor sentenced to 60 years in prison for child porn