Father of teenager who died of anorexia fears improved care not enough

Averil Hart - photo provided by the family
Averil Hart - photo provided by the family
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The father of a teenager who died of anorexia fears measures to improve care for people with eating disorders are not enough, and says others may have died in similar circumstances.

Community and mental health trust Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) was asked to apologise in writing and pay £3,000 compensation to the family of 19-year-old Averil Hart following an Ombudsman report which found failings in the way she had been treated, and that her death could have been prevented.

Yesterday Cambridgeshire County Council’s health committee heard about measures CPFT had taken to avoid any deaths like this in the future, but Averil’s dad Nic said he did not feel enough had changed and questioned whether everything was “good and rosy in the garden now?”

He added that Averil’s death had been “completely avoidable”. He told the committee the coroner was looking into other deaths “of a similar nature” and said problems in the health system had contributed to his daughter’s death.

“It is the lack of basic care,” said Mr Hart. “The Cambridge coroner has set an inquest date in September and said there are several other deaths of a similar nature they will be looking at. We have a failure of a service here.”

CPFT chief executive Tracy Dowling, who arrived at the organisation after Averil’s death, said a lot of work has gone into trying to address some of the trust’s shortcomings, but that it would be impossible to “eradicate all the risks”. She said some patients simply would not want to engage.

Changes made include making sure there is a “clear focus” on the need for acute staff to recognise life-threateningly ill patients with anorexia, as well as recognising “extreme frailty not usually seen in younger people”.

The service will also work with universities where young people are studying and has provided teaching and training to the University of East Anglia Counselling Service and also to Anglia Ruskin University counselling services.

When young people in the care of eating disorder services move to the area to start university, the CPFT service will consult with the university or college nurses, as well as support services and students’ GPs.

Moreover, in early autumn the trust will lead a regional seminar regarding safe and effective care for patients with severe anorexia nervosa, focused on where care is shared with GPs and where patients present with acute physical ill health.

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 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 were made 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.

Speaking at the meeting Cllr Linda Jones said getting universities to join up to share information that may save patients’ lives should be welcomed, and said the measures being taken by CPFT should be adopted nation-wide. She referenced the Healthy Universities Network (a UK-wide network which promotes health and wellbeing information among the country’s universities) and suggested they were brought on side to help distribute information that might help.

Cllr Anna Bradnam said many students were facing increased financial strains and stresses, and said she wondered whether this was leading to more young people, and students in particular, to fall out of the “framework” that allowed them to eat healthily on a regular basis.

Josh Thomas, Local Democracy Reporting Service