Failed at every level: Death of anorexic UEA student was an ‘avoidable tragedy’, damning report reveals
PUBLISHED: 07:43 08 December 2017 | UPDATED: 14:38 08 December 2017
The deterioration and death of an anorexia sufferer just 10 weeks into her first term at university was tragic and avoidable, a damning report being laid before Parliament today reveals.
Every single NHS organisation involved in the care of University of East Anglia (UEA) student Averil Hart failed her in some way, according to the findings of a Parliamentary and Health Service Ombudsman (PHSO) investigation.
The 19-year-old collapsed in her flat at the UEA on December 7, 2012.
She was rushed to Norfolk and Norwich University Hospital (NNUH) with a dangerously low temperature, blood sugar and blood pressure – but it was three days before medics realised the seriousness of her illness.
Doctors transferred her to Addenbrooke’s Hospital in Cambridge on December 11 – but she was not seen for five hours. She died on December 15, suffering a heart attack and brain damage from the low blood sugar.
Five years on, the PHSO report into her care lays bare a catalogue of failures by the Cambridge and Peterborough Foundation Trust (CPFT), who ran the Norfolk Community Eating Disorder Service (NCEDS), UEA Medical Centre, Addenbrooke’s (CUH) and NNUH. The document suggests a “very significant” deterioration in Averil’s health went unrecognised, despite her losing weight at an alarming rate.
Ombudsman Rob Behrens CBE wrote: “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 to her death. The NHS must learn from these events, for the sake of future patients.”
Although the actions of all four NHS organisations are criticised, Averil’s father Nic, from Sudbury, thinks it does not go far enough. He said: “Averil’s death matters to all of us because the tragedy is synonymous with the ongoing national failings within the NHS and also within the investigation process when things go wrong. 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, our friend, and all we want are honest answers. Why did our beautiful daughter die?
“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. If lessons are not learned, more people will die.”
MORE: Family searching for answers three-and-a-half years after death of UEA student
Averil began studying for a degree in English and creative writing at UEA in August 2012, after spending 11 months at the Cambridge Eating Disorder Unit. GPs at the UEA Medical Centre, were told to monitor her condition weekly. While there, she had six sessions with a care coordinator – who had no experience of looking after anorexia patients – and saw a GP three times. During her last appointment, a locum GP told her not to come back for a month.
On November 28, Averil’s father and sister visited her and were shocked by how much weight she had lost. They made an emergency call to the Eating Disorders Unit. A medical review was arranged for December 7, but Averil collapsed that morning.
The PHSO found responses to Mr Hart’s requests for answers after his daughter’s death were delayed and “appeared evasive”.
MORE: Anorexic UEA student, 19, failed by medics, says report
It said the local investigation into Ms Hart’s death was “wholly inadequate with the organisations involved being defensive and protective of themselves, rather than taking responsibility”.
He said they did not uncover serious failings – adding that their complaint handling was so poor that it was “maladministration”.
CPFT chief executive Tracy Dowling apologised to Averil’s family and friends on the trust’s behalf. She added: “We have implemented a number of new guidelines and processes for managing high-risk patients with eating disorders. We will review the ombudsman’s findings and we fully support the report’s recommendations.”
An NNUH spokesman said: “We met Averil’s family in 2014 to offer our sincere condolences for their sad and devastating loss. Since then we have taken into account the learning from this tragic event and our structure and processes have been reviewed.”
Representatives for UEA Medical Centre said: “We would wish to reiterate our sincere condolences to the Hart family. We will now be taking the time to read carefully and reflect upon the Ombudsman’s findings.”
A spokesman for CUH said: “When Averil was transferred to Addenbrooke’s she was already very unwell but her death, at that time, may have been avoided. A thorough investigation has been carried out, lessons have been learned and changes made.”
Norwich-based charity speaks out
Beat, the UK’s eating disorder charity which is based in Norwich, urged the government and NHS England to take prompt action.
Andrew Radford, chief executive said: “The PHSO report is very clear: if the eating disorder had been recognised earlier and effective and timely care was put in place, Averil Hart’s death would have been prevented. We await a response from the government and NHS England who must learn and take action following this tragedy; we cannot continue to fail people with eating disorders.
“We must see good, joined-up intensive home- and community-based treatment for people of all ages, and in all locations across the UK. This does require the NHS to reorganise but it will deliver improved outcomes for patients and considerable cost savings to the NHS.”
The government has set targets to reduce the time children in England spend waiting for treatment, but not for adults. Research by Beat has found that sufferers face an average three-and-a-half-year delay between symptoms developing and treatment starting, even though the likelihood of a prolonged and fast recovery significantly decreases three years after falling ill. Delayed treatment contributes to the NHS spending £4.6bn a year treating eating disorders.
“The government must invest in promoting the importance of seeking help for an eating disorder as soon as possible, so permitting early treatment which would prevent deaths like Averil’s,” said Mr Radford.
“It is also clear there were multiple failings across the health service in the lead-up to this tragedy, and the behaviour of each responsible part of the NHS in evading and obfuscating justice is appalling, and piled even more distress on an already distraught family. This requires further investigation and action taken to ensure it cannot be repeated.
“This tragedy demonstrates, once again, the devastation eating disorders can cause. The Hart family have not only had to grieve for their daughter, but also had to face the fact that her death could and should have been prevented.
“We extend our respect to Averil’s family for their courage and determination to see justice for their daughter. This report should help ensure that future eating disorder sufferers don’t suffer the same fate.”
Junior doctors should be trained on eating disorders
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.
Dr Bill Kirkup, who led the investigation, said: “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.”
Mr 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 - I hope that our recommendations will mean that no other family will go through the same ordeal.”
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.
“We’ve seen the creation of such teams for children and adolescents over the past two years.
“We need the same for adults with eating disorders, because tragedies like this should not happen just because someone has passed their 18th birthday.
“Eating disorders are the business of all doctors. Patients with eating disorders can show up anywhere in the health system and every doctor should be able to recognise the signs.
“From medical school upwards, eating disorders training for doctors is negligible. It should not be down to sheer chance if a trainee doctor gets any experience in treating eating disorders at all.
“The case of Averil is tragic, and we hope the Government takes note of this report so that her family and friends know these mistakes won’t be made again.”