VIDEO: Peterborough's mental health trust slammed by watchdog over death of anorexic woman and inadequate investigation

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, according to the Parliamentary and Health Service Ombudsman (PHSO).

The trust was also heavily criticised for its investigation into Averil’s death, which was described as so poor that it was “maladministration.”

This is the third time in the last two months where the trust’s actions have been criticised following a patient’s death.

An inquest last month found neglect contributed to the death of grandmother Heather Loveridge who set herself on fire.

Heather (56), who had a history of burning herself, was found engulfed in flames in her bedroom’s ensuite toilet within a day of being voluntarily admitted to the Cavell Centre in Peterborough,

A month earlier, an inquest into the death of former Gurkha soldier Prem Rai (39) found that there were failures in the hours before his death, also at the Cavell Centre.

Averil, from Sudbury, died in December 2012. She was voluntarily admitted to the Eating Disorders Unit at Addenbrooke’s Hospital in Cambridge - which is run by the Cambridgeshire & Peterborough NHS Foundation Trust (CPFT) - 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 the outpatient eating disorder services in Norfolk, which is also run by CPFT, for ongoing treatment.

But while there a number of mistakes in her care, and after her health deteriorated she was found unconscious on the floor of her student flat by a cleaner just four months later.

She was then transferred to a gastroenterology ward at Addenbrooke’s, run by the Cambridge Acute Trust, where her blood sugar was not properly monitored.

She died on December 15, 2012.

According to the Mail Online, Averil’s father Nic Hart (59) spent £200,000 investigating her death.

He said: “The care that Averil received was Third World – they left a high-risk patient to fend for herself.”

The PHSO report stated: “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.”

Tracy Dowling, chief executive of Cambridgeshire and Peterborough NHS Foundation Trust, said: “The death of Averil Hart in 2012 was a tragedy and we would again like to extend our apologies to her family and friends.

“Since her death we have implemented a number of new guidelines and processes for managing high-risk patients with eating disorders to ensure all lessons continue to be learned.

“We will review the Ombudsman’s findings and we fully support the report’s recommendations around how the funding of eating disorder services, including the recruitment and training of staff, can be improved nationally.

“The treatment of eating disorders is highly challenging and our specialist staff remain committed to providing the very best care to help people overcome their complex conditions.”

Asked if patients should be confident using the trust’s services after it was criticised in three recent reports, Ms Dowling said: “It’s a tragedy when someone dies and it’s our duty to ensure that any improvement required is made.

“There is no clinical link between this case that happened in 2012 and any of the other cases which have featured in the news of late, and the Trust’s average mortality rates are in line with national figures.”

TimelineThe report details that:

. Averil was voluntarily admitted to the Eating Disorders Unit at Addenbrooke’s Hospital in Cambridge - which is run by the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) - aged 18 in September 2011

. She was an inpatient there for 10 months before being discharged so she could take up a place at the University of East Anglia

. She was transferred to the Norfolk Community Eating Disorder Service (NCEDS), which is also run by CPFT, but joint working between the two units was “poor.”

. When Averil did move there was a delay in allocating a care coordinator by NCEDS which meant that she was not supported or properly assessed for a further month, during which time her condition deteriorated and her weight decreased significantly again. When she was first weighed in Norwich, she had lost 6kg

. The care coordinator that was then appointed by NCEDS had no experience of looking after people with anorexia nervosa. The support provided by the trust to the clinician was described as “inadequate.”

. When Averil’s care coordinator went on leave no cover was arranged. She was under the care of NCEDS from September 2012, but her condition “deteriorated markedly through to late November,” yet was no picked up.

. The GPs of the University of East Anglia Medical Centre, which was looking after Averil’s physical health, also failed to spot her deteriorating

. A lack of communication between the GP practice and NCEDS led to the former wrongly concluding that they could reduce their “already inadequate level of physical monitoring still further.”

. Averil’s deterioration continued and by the end of November she was “very unwell and her weight had dropped to an alarming extent.”

. Averil’s father visited her on November 28 and immediately recognised the marked deterioration in her condition over the preceding month. He contacted the Eating Disorders Unit at Addenbrooke’s. The report states: “Averil’s consultant during her admission declined to take the call although Mr Hart could hear her instructing that he be directed to NCEDS.”

. On December 7 Averil was found collapsed in her room and was taken by ambulance to the emergency department of the Norwich Acute Trust, but the urgency of addressing her condition was “not recognised” and she saw no specialist eating disorders clinician for three days after admission, by which time her condition had deteriorated further

. Averil’s condition, once finally recognised, saw her transferred to a gastroenterology ward at Addenbrooke’s Hospital, run by the Cambridge Acute Trust, on December 11, but she was not seen by a doctor for almost five hours

. That evening her blood glucose fell further to a level that was clearly life-threatening. She then refused treatment

. Averil became increasingly critically ill overnight, with extremely low blood glucose levels. No definitive action was taken and she was found unresponsive the following morning. It became clear that she had severe brain damage due to extremely low blood glucose and that further restorative treatment was futile

. Averil died at 11pm on December 15, 2012, with her family by her side

. Her family’s attempts to find answers led to “piecemeal investigations” and resulted in “an unsatisfactory process that was unlikely to generate a complete account of what had gone wrong.” Information stored electronically was also deleted

. The report states: “The Cambridgeshire and Peterborough Trust’s handling of Mr Hart’s complaint was so poor that it was maladministration.”

. The report’s conclusion on the investigations adds: “Individually, these failures are seriously unsatisfactory. Taken collectively, they paint a consistent picture of unhelpfulness, lack of transparency, individual defensiveness and organisational self-protection that is of great concern.”