Anger over nine year ‘delay’ and £200k legal fees following anorexic teen’s death

Averil Hart (19) passed away in 2012.

An inquest into her death last year concluded with the verdict that her death “could have been avoided and... was contributed to by neglect”.

Sean Horstead also carried out inquests into four other women who died from eating disorders while under the care of Cambridgeshire and Peterborough NHS Foundation Trust.

In his report, written after hearing the five inquests, the assistant coroner for Cambridgeshire wrote to Health Secretary Matt Hancock outlining concerns including: inadequate training of doctors and other medical professionals, a lack of commissioned provision to monitor patients and a lack of “robust and reliable data regarding the prevalence of eating disorders”.

He said he was “concerned that there may also be a significant under-reporting of the extent to which eating disorders have caused or contributed to deaths” and that the outlined problems could be “significantly exacerbated” by the Covid pandemic.

Mr Horstead has now received written responses from five senior officials with responsibility for healthcare provision and training across the country, including the NHS and the Government.

The responses all highlighted efforts which have been made in the nine years since Averil’s death to improve the system for eating disorders, including enhanced training and new pilot schemes which are about to get off the ground.

But the recent publication of all five replies has angered Averil’s dad Nic Hart and Simon Brown, whose daughter Emma was one of the five women who died.

Both men believe the nine year gap between Averil’s death and the written responses has been far too long and could have resulted in more people suffering needlessly.

Mr Hart also queried the £197,671 paid by CPFT (or its insurers) in legal costs and expenses in relation to Averil’s death, which includes the inquest, information requests an investigation by the Parliamentary and Health Service Ombudsman (PHSO) which concluded in 2017 that Averil died following a series of failures that involved every NHS organisation that cared for her.

Mr Hart said: “Why has it taken nine years since Averil died to appreciate that we need more trained doctors and nurses to treat the 1.25 million people who suffer from eating disorders?

“With the Covid crisis so many young people have suffered from increased anxiety and succumbed to eating disorders. If the health service spent less on the legal defence of their reputation and more on patient care many people would get the treatment they need and deserve.”

Mr Brown said he was really upset by eight years of “denial, defend and obstruction”.

He added: “I question whether the system is any better, whether people are interested in learning from mistakes and acting upon them. Because if they are, why has it taken four years to get to this point from the ombudsman report?”

“If you just look at Averil’s story, she died nearly nine years ago and it’s taken that long for this inquest to happen and for these responses to come out. That is a ridiculously long time.

“If we had a different approach to learning when things go wrong, maybe those lessons would be taken more seriously, maybe they would come out a bit quicker, and maybe those lessons if acted upon could have helped Emma and others who have died since Averil Hart’s tragic death nine years ago.”

The responses to the inquest can be read in full at: https://www.judiciary.uk/publications/averil-hart/.

To contact PEDS, visit: https://www.pedsupport.co.uk/.