Father of Norwich student disputes report which claims lessons have been learned after her death
The father of a 19-year-old University of East Anglia (UEA) student who suffered with anorexia has refused to accept a new report which found lessons had been learned from her death.
Averil Hart was just 10 weeks into her first term in Norwich when she collapsed in her flat at 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.
An investigation by the Parliamentary and Health Service Ombudsman (PHSO) last year found every single NHS organisation involved in her care failed her.
At the time ombudsman Rob Behrens CBE wrote: “The NHS must learn from these events, for the sake of future patients.”
Now, a report from the Norfolk Safeguarding Adults Board (NSAB) claims those lessons have been learned.
But Nic Hart, Averil’s father who has led a passionate campaign for justice, said he did not accept the findings.
Mr Hart, from Sudbury, Suffolk, said: “These are the same people who told me Averil’s care was satisfactory in the first place.”
And he struggled to see how one review in November 2017 had found no progress, but just 20 weeks later a second review said there had been headway made.
Commissioners said this was because in November the PHSO investigation was ongoing so they could not provide evidence of improvements to the NSAB.
But Mr Hart said: “There was five years with no change to November 2017 and then 20 weeks later, is it really better?”
He said through his campaign to hold organisations to account, he was still being contacted by others who were struggling to access help and whose family members had died.
He said: “My sense is that pressure has been brought to bear for people to do the paperwork, but nothing much is changing on the ground.”
Mr Hart said the family was now waiting for an inquest date, where they hoped for more answers.
All of the organisations involved in Averil’s care previously said they had taken into account lessons from the tragedy.
At the Norfolk and Norwich University Hospital a spokesman said the hospital’s nutrition team had expanded and included three consultant staff, while across the trust there was better recognition of eating disorders.
At Cambridge and Peterborough Foundation Trust - which runs the Norfolk Community Eating Disorder Service - chief executive Tracy Dowling previously said they had implemented new guidelines and processes for managing high-risk patients.
Addenbroke’s Hospital said “lessons have been learned and changes made”.
North Norfolk Clinical Commissioning Group also said changes had been made and reiterated their “sincere apologies for any lapses in care and once again our thoughts remain with her family”.
UEA Medical Centre previously said they would reflect on the findings of the ombudsman.
All organisations also expressed their condolences to Averil’s family.