‘Substantial failings’ made during investigation of anorexic teen’s death, report concludes
The dad of a teenage girl who died from anorexia has received an apology after “substantial failings” were made during an investigation into her death.
Averil Hart (19) died following a series of failures that involved every NHS organisation that cared for her, including the Cambridgeshire & Peterborough NHS Foundation Trust, a report released by the Parliamentary and Health Service Ombudsman (PHSO) concluded.
However, the PSHO has now admitted it made a series of errors during its investigation, including making promises to Averil’s dad Nic that could not be guaranteed.
The independent adjudicator of NHS disputes has now released a review into its original investigation, which concluded: “There were substantial failings in PHSO’s handling
of Mr Hart’s complaint.
“PHSO’s actions – and, in some cases, inaction - undermined Mr Hart’s trust in the quality and impartiality of its investigation.”
It added: “The failings combined to result in lengthy delays to the investigation at an extremely difficult and upsetting time for Mr Hart and his family who were grieving for a loved one.
“PHSO has already placed on record its sincere apology for the way this investigation was handled. Following this detailed review, PHSO would again like to apologise for the many failings identified and for the distress experienced by the complainant and his family.”
Averil, from Sudbury, was voluntarily admitted to the Eating Disorders Unit at Addenbrooke’s Hospital in Cambridge - which is run by the CPFT - aged 18 in September 2011, then received treatment from other NHS providers.
But after a series of failings in her care she died on December 15, 2012, with CPFT’s subsequent investigation into her death described as “maladministration” by the ombudsman.
The trust has said a number of changes have been made since Averil’s death, including putting in place a policy for eating disorder patients who are classed as high risk.
The PSHO investigated Averil’s death after receiving a complaint from Mr Hart in August 2014. It concluded in December 2017 - more than three years later - that her death was an “avoidable tragedy” that would have been prevented had the NHS provided appropriate care and treatment.
Averil weighed less than five stone when she died, and a coroner is currently investigating whether there is a link between her death and that of four other young women from eating disorders.
But despite the PSHO’s investigation revealing a number of failings in the NHS, Mr Hart was unhappy with how it was carried out, with the ombudsman agreeing to internally review its handling of the case.
The review, which was led by a manager in PHSO’s senior leadership team who was not employed during its handling of Mr Hart’s original complaint, was released yesterday and contained a number of criticisms.
. The length of the original investigation being double what should be expected
. A request from a manager for a second caseworker to be assigned to the case being turned down, leading to “significant delays”
. Senior managers directing caseworkers to draft individual reports on each of the NHS organisations Mr Hart had complained about, before nearly two years later changing this to a single report into the whole case
. Five caseworkers and seven managers working on the investigation at different times, with Information “sometimes lost because handovers were not always handled effectively”.
. A failure to ensure information was stored or shared securely after an external investigator appointed to the case offered Mr Hart his private contact details
. Senior managers directing caseworkers to change their approach in how they carried out the investigation, resulting in Mr Hart receiving “mixed and sometimes contradictory messages”
. Inconsistencies in seeking evidence from health professions - ”the delays and contradictions would have made it understandably hard for Mr Hart to have confidence in PHSO’s investigation,” it was noted
. A failure in impartiality after a senior manager told Mr Hart that all the failings he had identified would be upheld before the investigation had been completed. In the end this proved to be incorrect.
The report also reveals that Mr Hart was told by senior managers he would receive financial compensation from the NHS organisations highlighted in the investigation, but that this was never followed up. As a result the PSHO has offered to make a “significant exceptional payment” to Mr Hart which so far he has not accepted.
However, the report notes: “Since Mr Hart’s complaint was concluded there have been significant improvements in PHSO’s approach to handling complaints drawing on lessons learnt from this case.
“In each area where failings have been identified, PHSO has either made improvements or is in the process of making improvements to help make sure it will not make the same mistakes again.
“The review did not identify any gaps where further changes to PHSO’s approach to handling complaints should be considered.”
The review has now been published online and will be shared with a committee of MPs which holds the PSHO to account.
To read the review in full, visit: https://www.ombudsman.org.uk/sites/default/files/PHSO_Handling_Of_Mr_Nic_Harts_Case.pdf.