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The death of a teenage girl who died of anorexia “could have been prevented” and “was contributed by negligence” due to failures in her care, an investigation concluded.
Averil Hart died at age 19 in December 2012, ten weeks after starting college.
At the conclusion of the investigation into his death, Cambridgeshire and Peterborough Assistant Medical Examiner Sean Horstead described NHS treating patients with anorexia as “an unsafe system”, adding that it “leads to a risk of death in the future.”
Averil Hart was 19 years old when he died of anorexia.
It will now submit a “Future Death Prevention Report” to the NHS England outlining concerns from a series of investigations into the deaths of patients with anorexia nervosa.
He listed several occasions where intervention or provision of more appropriate treatment would have prevented Ms. Hart’s death.
She had spent almost a year as an inpatient in a specialist eating disorder unit in Cambridge, but was discharged in August 2012 because she really wanted to go to university.
A plan was made for her care and she was supposed to be seen weekly by the University of East Anglia Medical Service.
However, many of those appointments did not take place.
Counseling had been arranged for him, but an apprentice took care of it.
The coroner said Ms Hart could have survived if she had received the ‘appropriate’ support
In November she was visited by her family and her father was so concerned that he raised the alarm to the health services, but her concerns were not taken into account.
The coroner found that if the intervention had taken place, it is likely that his subsequent collapse would not have occurred and said it was a “significant error in judgment not to contact Mr. Hart and obtain more details.”
On December 7, 2012, ten weeks after starting college, she was found collapsed in her residences.
She was admitted to Norwich hospital, where the coroner concluded that “if adequate nutritional support had been provided to Averil … she would have survived.”
Instead, they told him to get food from a cart.
He passed away on December 19.
Averil’s father, Nic Hart, said: “It took seven years for Averil’s family to finally receive a formal investigation into his tragic death.
“During those seven years, other patients have died needlessly, largely due to the poor quality of the three-and-a-half-year investigation by the Ombudsman (PHSO), but also due to a lack of open and honest disclosure on the part of the NHS trusts who was responsible for the care of Averil.
Averil Hart with his father
“The Averil case has highlighted the desperate need for open and honest disclosure when things go wrong, so other patients don’t suffer in the same way.”
Hart added: “The sadness of losing Averil will always be with us, but we hope the Secretary of State for Health will ensure that the changes proposed by NHS England and NHS Improvement are implemented immediately. “
Andrew Radford, executive director of the eating disorders charity Beat, told Sky News that “Mental illness has always been the poor relative in the health service, as eating disorders have often been underestimated as mental illnesses that are”.
He added: “They are often dismissed as failed diets or manners and that is far from the truth.
“They are serious mental illnesses that cause lasting damage to health and in sad cases death.
“Unfortunately, it is quite possible for a medical student to go through their training and qualify as a physician without having a single moment of training on how to identify or treat an eating disorder.
“Although we have a system like this and in the case of medical education nobody really takes responsibility for addressing it correctly, we are going to continue to have problems.”
Dominique Griffin was 17 years old when she was admitted to the hospital for anorexia.
Doctors told him that he was only days away from death.
“You feel trapped,” he said. “The whole day revolves around the eating disorder.
“You feel like you have no one to talk to because no one understands you.”
Now fully recovered, the 27-year-old from Hawley is married with a young daughter. He thinks he owes his life to the treatment he received.
“I don’t think I would be here today and I thank my lucky stars every day for how they decided to treat me,” he says.
She believes her recovery is proof that Averil, too, could have overcome the disease with proper treatment.
“It makes me angry that I didn’t get the help I needed. It makes me very angry because I could have had a life,” she says.
“There is life after an eating disorder. I know some people don’t see a way out, but there is a way out.”
An NHS spokesperson said: “All services involved must act on the important and deeply troubling findings and learning established by the coroner.
“The NHS will continue to expand and improve access to eating disorder services, including in Cambridgeshire and Peterborough, to strengthen the way adult eating disorder services work together.”
