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.