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The death of a teenage college student with anorexia could have been prevented and was due to negligence, an investigation concluded.
Averil Hart, 19, a black belt in karate and academically gifted, began her first term at the University of East Anglia (UEA) in Norwich in September 2012.
She had a three-year history of anorexia and had been discharged from the eating disorders unit at Addenbrooke Hospital in Cambridge the previous month, following an 11-month stay.
She lost weight during her first term and was taken by ambulance to Norwich Hospital after she was found collapsed in her room on December 7.
She was transferred to Addenbrooke’s on December 11 and died there on December 15.
Cambridgeshire assistant coroner Sean Horstead has overseen separate investigations into the deaths of five women with anorexia and said, after concluding Hart’s investigation, which was the last of five hearings, that he would write to bodies like England’s NHS. to raise a number of concerns.
Recording a narrative conclusion in Hart’s case on Friday, he said: “Averil Hart’s death could have been prevented and … his death was contributed by negligence.”
He recorded the medical cause of his death as anorexia.
Horstead said that, on the balance of probabilities, a series of failures “contributed more than minimally to his death” and that these included the lack of a service commissioned for the medical follow-up of a patient with anorexia at high risk of relapse.
He also said Hart was assigned to an “inexperienced psychologist-in-training” in the middle of a “staffing crisis” at the Norfolk Community Eating Disorder Service (NCEDS).
There was a “missed opportunity” when Hart’s father, Nic Hart, raised concerns about his daughter’s condition more than a week before her collapse, but no one at NCEDS spoke to him directly, Horstead said.
He added that “no adequate nutritional support” was provided to Hart during his four-day stay at Norfolk and Norwich University Hospital (NNUH).
“In the context of her severely malnourished condition recognized at the time of admission, this was a serious failure that had a direct causal connection to her death and contributed more than minimally to her death,” Horstead said. “Therefore, negligence contributed to Averil Hart’s death.”
Lack of support over the weekend from psychiatrists and dietitians at NNUH and lack of control of her anorexic behaviors while in the ward, where she fell and hit her head and was asked to complete her own table of food also contributed, Horstead said. He added that delays during the Addenbrooke hospital admission process “possibly” contributed to his death.
“However, given the already very slim chance of survival Averil faced after his stint at NNUH prior to his arrival at Addenbrooke’s, it can only be safely concluded that these failures possibly contributed more than likely to his death,” he said.
The Peterborough Town Hall hearing followed previous investigations into the deaths of Maria Jakes, Emma Brown, Madeleine Wallace and Amanda Bowles, which had now concluded.
Horstead said that “the absence of a formally commissioned follow-up service in primary or secondary care is the context in which several of these deaths have occurred.”
He said GPs are “generalists by definition” and anorexia is a “relatively uncommon condition for a generalist to treat,” but it was also “unreasonable” to expect “struggling secondary services to be fully responsible without hiring. of a Service “.
