A teenager, who died from anorexia, was an “avoidable tragedy”, a report has found.
Averil Hart, 19, from Newton, near Sudbury, died in 2012 after her condition deteriorated following “missed opportunities” by the NHS.
An investigation conducted by a Parliamentary and Health Service Ombudsman found a “series of failures by every NHS organisation that should have cared for her.”
Averil had suffered with anorexia nervosa for three years but, after more than 10 months as an inpatient at Cambridge University Hospital, she was discharged to study at East Anglia University in 2012.
The report found that “multiple opportunities” had been missed in preventing her deterioration between the time she was discharged in August and her eventual death in December.
Prior to the move, her weight and mental health were “inadequately monitored” while her condition was described as “severe”.
The report stated: “Averil was assessed as fit for discharge, although it was recognised that she was vulnerable to subsequent relapse.”
The ombudsman found the care plan had failed to provide “explicit documentation of warning signs of deterioration in Averil’s condition and a contingency plan to be invoked if they materialised”.
It said: “The care plan at discharge failed to set these out robustly or explicitly enough.”
After moving to Norwich, Averil’s care was divided between GPs at The University of East Anglia’s medical centre, and the Norfolk Community Eating Disorder Service (NCEDS) at Cambridge and Peterborough Trust.
The findings, however, found that her GP failed to follow up on her condition after the referral, or allocate a single GP which meant “there was no single point of oversight”.
During November, Averil was told to return to her GP a month later, despite the importance of her being monitored weekly.
The practice failed to inform the change of plan to NCEDS, which meant Averil’s condition was not effectively monitored.
The report stated: “Had the GPs done as they were asked, the deterioration in Averil’s physical condition would have been recognised sooner and action taken before she reached the point of collapse.”
Averil was not properly assessed for a month by NCEDS, during which time her weight plummeted.
The ombudsman found the failure of assessment, co-ordination and care planning during this time “all represent missed opportunities to recognise that Averil’s condition was deteriorating and that she was at significant risk”.
The care co-ordinator finally appointed had no experience of treating Averil’s condition, while the hospital had failed to provide other medical experts to assist with her treatment.
“The failure to provide multi-disciplinary team support left the care co-ordinator as the sole point of contact with Averil, and impaired the ability to detect deterioration in her mental and physical condition,” read the report.
During a visit in late November, Averil’s father found his daughter’s condition had seriously deteriorated and contacted NCEDs, which arranged an appointment and medical review for the following week.
The appointment, however, was cancelled by Averil, who was found collapsed the next day in her room at university. She was severely underweight with low blood pressure and blood glucose.
She was taken to the Norwich Acute Trust, which the ombudsman report found had failed to recognise Averil’s condition as life-threatening.
An effective refeeding regime had not been carried out and the report’s findings stated that the trust’s actions “fell far short of what should have happened”.
Overnight, Averil’s condition was critical but “no definitive action” was taken after a telephone call between a junior doctor and a consultant.
The following morning, on December 15, Averil was found unresponsive from severe brain damage caused by low blood glucose. She died with her family by her side.
Following the report, Rob Behrens, Parliamentary and Health Service Ombudsman, said: “This was a serious complaint involving several NHS organisations.
“We took too long to complete the investigation and I sincerely apologise to Mr Hart and his family for the delay.
“Our investigation found that Averil’s tragic death would have been avoided if the NHS had cared for her appropriately.
“Several NHS organisations missed opportunities to prevent the deterioration, which led to her final admission to the hospital where she died.
“We also found inadequate co-ordination and planning of Averil’s care during a particularly vulnerable time in her life, when she was leaving home to go to university.
“There were also failures in her care and treatment in two acute trusts when she was seriously ill. Sadly, these failures, and her family’s subsequent fight to get answers, are not unique.
“We have spoken to system leaders and experts in the field about the state of eating disorder services.”