Last December, the Parliamentary and Health Service Ombudsman ruled that 19-year-old Averil Hart’s death from anorexia was an “avoidable tragedy” that would have been prevented had the NHS provided appropriate care and treatment.
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 then received treatment from other NHS providers.
Averil died on December 15, 2012, with CPFT’s subsequent investigation into her death described as “maladministration” by the ombudsman.
The Peterborough Telegraph has interviewed Averil’s grieving father Nic about his quest for the truth and CPFT’s new chief executive Tracy Dowling about what changes have been made following Averil’s death and the overall state of community and mental health services.
Nic Hart was holding his daughter’s hand when she passed away, weighing less than five stone.
“We spent the last five days of her life with her. We were holding her hand when she died,” he said.
“It was 11 o’clock on a Saturday night and nobody was around. We just sat in the car for a while then drove home. I’d been there five days sleeping on the floor.”
Since that fateful day in December 2012 Mr Hart has been fighting to learn why his daughter died.
And what hurt the most as the facts were finally established was that he feels Averil should still be alive today.
“What’s so tragic is it was a treatable illness. Although it has a high mortality rate, if treated successfully people survive it,” he said.
“She was really outgoing and very sociable. I had so many people in the ward saying how she kept them amused and gave them hope.”
The ombudsman report was vindication for Mr Hart, but he believes there are still many questions to be answered.
For instance, why were emails about his daughter’s care deleted? And why was Averil’s case removed before the publication of new MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guidelines?
Mr Hart (59) claims he has a copy of an internal trust email which asks for influence to be put on the author of the guidelines to stop Averil’s case from being included.
The email ends: “There is potential reputational damage of the service and trust at stake.”
On top of that, Mr Hart believes if the warnings he had tried to make had been listened to, Averil would still be here.
And he is upset that he received a letter from Julie Spence, the CPFT chair, a year before the ombudsman’s report came out which stated that the trust did not “accept that any failures or shortcomings on the part of this organisation or its staff caused Averil’s death.”
In January, Mr Hart had a three hour meeting with CPFT chief executive Tracy Dowling who came into the role long after Averil died.
Reflecting on the meeting, he said: “The sense I got is she wants to be open and honest dealing with us, but she has to go through the board.
“Until the board ratifies the idea of an open and honest approach that Tracy Dowling says she would like to see, I’m not sure she can deliver it.”
Mr Hart has now been told there is to be a coroner’s inquest into Averil’s death. He hopes that its conclusions might lead to a subsequent police investigation.
But he is also aware that more than five years have now passed since his daughter’s death and that her older two sisters also need their dad.
He said: “I have Zoe and Imogen to think about.
“You need to draw a line but there’s more to be done.
“There’s been no accountability. Averil’s care matters to everyone. Basic care was not done. It could be you or I going in there for something.
“And the situation that followed - they need to own up to it.”
Mr Hart, who runs a meteorological business, admitted the whole experience of seeking the truth has consumed him, but other members of the family have also suffered.
He added: “It’s soul-destroying. Not just for me. Averil’s sister suffered from depression as a result. She had to give up work in London and works with me locally.
“Averil’s mother really struggled losing her daughter. Averil’s boyfriend said he has lost five years. They were probably going to get married.
“The ripples have gone far and wide.”
Changes have been made at the Cambridgeshire and Peterborough Foundation Trust (CPFT) following the tragic death of Averil Hart, according to the trust’s chief executive.
Tracy Dowling said lessons have been learnt but that she is in the process of reviewing all the records and documentation from the case to make sure she can answer every question from Averil’s dad Nic.
Ms Dowling, who only started her current position last year, said she could also understand why Mr Hart would feel there had been a cover up, but that all staff members she has spoken to have assured her that they have been open, honest and candid.
She said: “Averil sadly died in 2012. Since then one of the changes has been to put in place across our eating disorder services a policy for patients who are classed as high risk.
“So that’s patients who either have a very low body mass index or patients who have lost weight really quickly. And those patients who are classified as high risk, they are reviewed every week by the whole multi-disciplinary team together.
“They review their weight, they review any other medical monitoring, they review progress with therapy, and as a team they agree what the next steps are.
“That team includes a psychiatrist, a psychologist, a therapist, a mental health nurse - so a wide range of people with specialist skills and expertise.
“I can’t say we will prevent everybody that has an eating disorder from dying - we can’t remove that risk. But what I can say is that I’ve seen some of the changes that have been put in place, and those changes certainly ensure we are aware who those high-risk patients are and that they are being actively supported and managed.”
Ms Dowling also said she was not anticipating any problems in making changes after Mr Hart said he had been disappointed at previous responses he had received by chair of the board, Julie Spence.
She said: “I don’t think I will struggle with the board. Julie has agreed that she and I will meet with Mr Hart. It’s important as chair she hears what he’s been through and what he wants to see.”
The trust has also recently been criticised following inquests into the death of grandmother Heather Loveridge, who set herself on fire, and the death of former Gurkha soldier Prem Rai.
Ms Dowling said: “They are all tragic cases. There is learning from them, the trust has been very clear about that learning and what needs to happen and those things are in place.
“Coming into the trust I have been hugely impressed with the skill of the staff and their commitment. They do enormously good work and lots of our patients recover and go into employment or education. CPFT has a very good safety record, it is a safe organisation. Our CQC rating is good. I feel very positive about CPFT. It’s a trust where certainly I would be absolutely happy for friends and family to use the services of this trust without a moment’s hesitation.”