Averil Hart, 19, died following a series of failures that involved every NHS organisation that cared for her, the Parliamentary and Health Service Ombudsman (PHSO) said as it warned of “widespread problems with adult eating disorders services in the NHS”.
Its investigation found inadequate coordination and planning of the teenager’s care during a particularly vulnerable time in her life, as she was leaving home to go to university. There were also failures in her care and treatment in two acute trusts after she became seriously ill.
Ms Hart, from Sudbury in Suffolk, was voluntarily admitted to the Eating Disorders Unit in Cambridge aged 18 in September 2011.
She had a three-year history of anorexia nervosa and was severely underweight with a significant risk to her physical health.
Over the following 11 months as an inpatient she slowly gained weight and doctors decided she could be discharged in August 2012 as she was very keen to take up a place at the University of East Anglia.
Still underweight, she was referred to outpatient eating disorder services in Norfolk for ongoing treatment.
But she was found unconscious on the floor of her student flat by a cleaner just four months later and transferred to Addenbrooke’s Hospital in Cambridge, where her blood sugar was not properly monitored. She died on 15 December 2012.
The PHSO report said all the NHS organisations involved in the teenager’s care and treatment between her discharge from hospital on 2 August 2012 and her death failed her in some way and her “deterioration and death were avoidable”.
Referring to complaints by her father Nic Hart, the report went on: “We found that most of the NHS organisations which dealt with Mr Hart’s complaint failed to respond to his concerns in a sensitive, transparent and helpful way.”
While Ms Hart began her university course in September 2012, she was not allocated a care coordinator until October.
Although she was meant to have weekly appointments with a doctor, she saw a GP on three occasions between 12 October and 8 November and at the last appointment a locum GP told her she did not need to come back for a month.
On the morning of 7 December, Ms Hart was found collapsed and taken by ambulance to A&E where she saw no specialist eating disorders clinician for three days after admission, by which time her condition had deteriorated further.
Nursing care was also said to be deficient and failed to monitor her condition effectively.
She was then transferred to Addenbrooke’s Hospital on December 11. Overnight her blood sugar fell to very low levels, but she did not receive appropriate treatment for this and became unconscious and suffered brain damage. She died three days later.
The report said: “Cambridge Acute Trust’s actions fell far short of what should have happened, and constituted service failure.
“This was the final failure that led immediately to Averil’s death, but it was the last of a long series of missed opportunities to recognise her deteriorating condition and intervene to prevent the need for her final hospital admission as an acutely ill medical emergency.
“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 from August 2012 to her death on December 15 2012.
“The subsequent responses to Averil’s family were inadequate and served only to compound their distress.
“The NHS must learn from these events, for the sake of future patients.”
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.
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.”
Ombudsman Rob 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.”
Other examples of cases were also given in the report, including that of a woman with a history of vomiting and binge eating, who died of heart failure after taking an overdose following a catalogue of errors by the NHS, including inconsistent and unhelpful therapy sessions.
The PHSO also apologised to Mr Hart itself for taking too long to complete its investigation.
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.”
A Department of Health spokeswoman said: “We are introducing the first ever eating disorder waiting time standards and investing £150 million creating 70 new community eating disorder services across the country, so that no-one will have to go through the same ordeal as Averil.”