Coroner to consider if five deaths relating to eating disorders are linked ahead of inquest into anorexic teenager

A coroner will consider whether the death of a teenager with anorexia is linked to four other deaths related to eating disorders.

Tuesday, 3rd September 2019, 4:04 pm
Averil Hart

Averil Hart (19) died in December 2012 after losing weight while starting at university in Norwich.

She had been discharged from an eating disorder unit at Addenbrooke’s Hospital in Cambridge in August the same year. The unit is run by the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT).

RELATED: Grieving father: My girl should be aliveSean Horstead, assistant coroner for Cambridgeshire, is overseeing the inquest into Miss Hart’s death.

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Averil Hart

He is also overseeing separate inquests into the deaths of four other people which relate to eating disorders.

He told a pre-inquest review hearing into the death of Averil that he is approaching the cases with an open mind.

“I have up until this point, and including this point, made no findings or determinations about any definitive link between any of the cases I’m currently reviewing,” Mr Horstead told Tuesday’s hearing in Huntingdon.

“That’s not to say, however, that there may emerge themes that are common to more than one of the inquest proceedings that I’m currently reviewing and have conduct in respect of.

“The potential for themes common to one or more of these to emerge is obvious.”

He said a senior coroner “deemed it appropriate for me to have and retain conduct of these matters”.

This would allow him to decide whether any common themes identified require him to issue a report to prevent future deaths, he said.

The Parliamentary and Health Service Ombudsman (PHSO) released a report in December 2017 titled 'Ignoring the alarms: How NHS eating disorder services are failing patients'.

It concluded that Averil's death was an “avoidable tragedy” that would have been prevented had the NHS provided appropriate care and


One of the four other cases being overseen by Mr Horstead pre-dates the publication of the report. It is the inquest into the death of Amanda Bowles (45) in September 2017.

The three other inquests concern women who died in 2018 after the publication of the report - Madeline Wallace (18) Emma Brown (27) and Maria Jakes (24).

Tuesday’s pre-inquest review into the death of Averil, which was attended by her father Nic Hart, was adjourned until March 2 for a full

inquest hearing which is expected to last three weeks.

Pre-inquest review hearings in the other four cases are expected to be heard this week.