Death of woman, 19, from anorexia was
avoidable, Ombudsman rules
A young woman's death from anorexia
nervosa would have been prevented had the NHS provided appropriate care and
treatment, according to a Parliamentary and Health Service Ombudsman (PHSO)
report published on Friday, 8 December 2017.
Averil Hart died on 15 December 2012, aged only 19, following a series of
failures that involved every NHS organisation that should have cared for her.
Her family subsequently brought a complaint about her care and treatment to the
The Ombudsman investigation, led recently by Dr Bill Kirkup, found inadequate
coordination and planning of Averil's care during a particularly vulnerable time
in her life, when she was leaving home to go to University. There were also
failures in her care and treatment in 2 acute trusts when she was seriously
ill. In addition, the local investigation into her death was wholly inadequate
with the organisations involved being defensive and protective of themselves,
rather than taking responsibility.
Conversations with system leaders and experts in the field suggest there are
widespread problems with adult eating disorders services in the NHS. These
concerns are reflected in the other casework examples within the report:-
"A severely ill woman with suicidal thoughts who was inappropriately discharged
from Hospital with an inadequate care plan in place, died from a heart attack
triggered by starvation. Another seriously ill woman with a history of vomiting
and binge eating died of heart failure after taking an overdose following a
catalogue of errors by the NHS, including inconsistent and unhelpful therapy
Commenting on the investigation, Parliamentary and Health Service Ombudsman Rob
Behrens, said:- "Averil's tragic death would have been avoided if the NHS
had cared for her appropriately.
Sadly, these failures, and her family's subsequent fight to get answers, are not
The families who brought their complaints to us have helped uncover serious
issues that require urgent national attention; I hope that our recommendations
will mean that no other family will go through the same ordeal."
Dr Bill Kirkup, said:- "Nothing can make up for what happened to Averil
and her family.
But I hope this report will act as a wake up call to the NHS and health leaders
to make urgent improvements to services for eating disorders so that we can
avoid similar tragedies in the future."
The report highlights 5 areas of focus to improve
eating disorder services:-
1. Training for all junior doctors on eating disorders to improve understanding
of these complex mental health conditions.
2. Greater provision of eating disorder specialists.
3. Adult eating disorder services to achieve parity with child and adolescent
4. Better coordination of care between NHS organisations treating people with
5. National support for local NHS organisations to conduct and learn from
serious incident investigations, particularly in circumstances involving several
The Parliamentary and Health Service Ombudsman is currently developing a new 3
year strategy, which will see the introduction of new ways of working to resolve
cases sooner and improve the overall experience of people making complaints.
Parents thank teachers this Christmas
with a donation to R Charity
TEACHERS and students at an outstanding
primary School in Bootle have pledged to raise funds for equipment and services
set for the new Royal Liverpool University Hospital this Christmas in a very
generous and selfless way.
Whilst many teachers in and around Liverpool will be receiving Christmas
presents on the last day of term, teachers and staff at St Monica's Catholic
Primary School in Bootle have asked parents not to buy gifts, but to donate ₤1
to their chosen charity, 'R Charity' as a thank you instead.
Christmas is an expensive time of year, and for those parents with more than 1
child in School, then buying gifts for teachers can be difficult. So head
teacher, Paul Kinsella is delighted with the positive reaction and response that
their campaign brings, and hopes that other Schools in the area will follow suit
and join in with the:- 'All I want for Christmas is ₤1' campaign.
Head teacher Paul said:- "It's such a pleasure to raise funds for charity
in this way at Christmas. It saves a lot of money at the most expensive time of
year, and eases the financial burden that can come with the buying of gifts for
teachers. But more importantly it sends out an excellent and strong message to
our children and their families about the power of everyone giving a little to
make a lot."
Paul is extremely proud to be supporting the new Royal Liverpool University
Hospital which will open in 2018. He said:- "We have fundraised for lots
of charities over the years and this year we have chosen to support R Charity,
the Royal Liverpool Hospital's charity. Our children's families and friends may
have to attend or be treated in this facility in the future, so we are really
proud to contribute to such a cause. It's a Christmas gift from the School to
the new Hospital, and to its patients and their families. It would be absolutely
amazing to see other Schools joining in to do the same this year."
It's a really simple and lovely request to make to parents; the fundraising team
at R Charity think it's a fabulous idea, and are extremely thankful to Paul, his
teachers, staff and parents at St Monica's Primary School.
Aimee Clare from the R Charity fundraising team said:- "What a generous
way to support our appeal this Christmas. Whether you are a teacher or not, it
is nice to receive chocolates and flowers at Christmas, so what a kind thing it
is to request donations in lieu of such gifts. A great big thank you to Paul. We
still have ₤3 million to raise, so thank you St Monica's! Can you imagine if 10
other Schools joined in collecting ₤1 for R Charity this Christmas? Collectively
a great lot of little will be raised towards our appeal."