Averil Hart, 19, was let down by every part of the NHS that should have cared for her, the Parliamentary and Health Service Ombudsman said
A student with anorexia starved to death after a series of NHS failures, a report finds today.
Former grammar school pupil Averil Hart, 19, was let down by every part of the organisation that should have cared for her, the Parliamentary and Health Service Ombudsman says.
Yet the four NHS bodies refused to take responsibility for the tragedy and instead were ‘defensive and protective of themselves’, the report says.
Ombudsman Rob Behrens warned that the case was only one example of ‘widespread problems with adult eating disorders services in the NHS’.
Miss Hart’s family, from Sudbury in Suffolk, last night condemned the ‘Third World care’ that had led to their daughter’s death – and asked why took five years for officials to uncover the failures.
She was found collapsed in her university room after losing 2st – nearly a third of her body weight – in less than three months.
Doctors had not properly tracked her weight or her mental health, and after she was rushed to A&E, two hospitals made basic blunders that accelerated her death.
Miss Hart, who had achieved five A*s at A-level at Colchester Royal Grammar School before starting a creative writing degree at the University of East Anglia, died on December 15, 2012.
When her family raised concerns about the care she had received, the NHS response was ‘piecemeal’ and ‘appeared evasive’, the report found.
Crucial emails relating to Miss Hart’s care were deleted in an apparent cover-up, and complaint handling by the two hospitals was so poor that it was defined as ‘maladministration’.
Averil Hart, who battled anorexia, lies in a hospital bed as her father Nic looks over her
Her father Nic Hart, 59, managing director of a weather equipment firm in Essex, spent £200,000 investigating her death.
‘The care that Averil received was Third World – they left a high-risk patient to fend for herself,’ he said last night.
‘Not only was the care that Averil received negligent, but the investigation of her death took far too long and this has resulted in further unnecessary deaths. We lost our beautiful daughter… and all we want are honest answers.’
He criticised the ombudsman for taking three and a half years to produce the report and for relying on the word of clinicians rather than actual medical records.
He had ‘failed to identify the fundamental causes of Averil’s death,’ Mr Hart said. The family released a photograph taken two days before she died.
Mr Behrens apologised for the delay in producing the report. He 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.
Miss Hart was found collapsed in her university room after losing 2st – nearly a third of her body weight – in less than three months
Doctors had not properly tracked Miss Hart’s (pictured, as a young girl) weight or her mental health during her anorexia, a Parliamentary and Health Service Ombudsman found
‘I hope our recommendations will mean that no other family will go through the same ordeal.’
Miss Hart had spent 11 months at the Eating Disorders Unit in Cambridge. Still underweight, she was discharged in August 2012 to take up her university place. Her care was taken on by the university GP service and outpatient eating disorder services in Norwich.
At her first appointment, on September 20, she weighed 6st 10lb. By December 10, she weighed just 4st 10lb having lost 29 per cent of her body weight. Although she was meant to have weekly appointments, in November a locum GP told her she did not need to come back for a month.
A trainee psychologist failed to track her weight and went on holiday without assigning alternative care. When her father and sister Imogen, 31, visited her at the end of November, they were shocked how much weight she had lost.
Mr Hart called the Eating Disorder Unit to raise concerns. Doctors said action would be taken but nothing was done. On the morning of December 7, Miss Hart was found unconscious on the floor of her room by a cleaner.
Miss Hart’s (pictured, as a young girl) father has criticised the ombudsman for taking three and a half years to produce a report on her death
The ombudsman’s report said four NHS organisations had failed Miss Hart in the period leading up to her tragic death
She was taken to Norfolk and Norwich University Hospital but failed to receive expert care and three days later was transferred to Addenbrooke’s in Cambridge. There, her blood sugar was not properly monitored.
She died four days later. The report said each of the NHS organisations involved had failed her and had not responded to Mr Hart’s complaint in a sensitive and transparent way, adding to the family’s distress.
‘The death of Averil Hart was an avoidable tragedy,’ it concluded, adding that the NHS investigation ‘was wholly inadequate’. The report calls for better training for junior doctors, and greater provision and coordination of care.
UEA Medical Centre, Cambridge and Peterborough NHS Trust, Norfolk and Norwich University Hospitals, and Cambridge University Hospitals last night each expressed ‘sincere condolences’ to the Hart family and said they would carry out the ombudsman’s recommendations.
The Department of Health said the tragedy and similar cases had led to ‘a step change’ in the way the NHS treats eating disorders.