Inquest into death of Averil Hart finds extensive failures

A Huntingdon inquest into the death of 19-year old Averil Hart has described extensive failures in the national support services for sufferers of anorexia.

Miss Hart, from Newton in Suffolk, died in December 2012 whilst studying creative writing at the University of East Anglia. She was admitted to the Norfolk and Norwich University Hospital (NNUH) on the 7th December after being found collapsed in her bedroom. She was transferred to Addenbrooke’s Hospital in Cambridge and died on the 15th.

Addenbrooke’s had previously been treating Miss Hart for her eating disorder for a period of 10 months, discharging her in August just before she began her first semester at UEA.

An inquest into the case was launched in March, following a report by the Parliamentary and Health Service Ombudsman (PHSO) which stated Miss Hart had been failed by “every NHS organisation that should have cared for her.”

On the 20th October Dr Katie Bramall-Stainer, chief executive of Cambridgeshire Local Medical Committee, told the inquest: “The national picture is one of a failure to have a sustainable, safe, evidence-based, adequately-commissioned position for patients to ensure long-term positive outcomes.”

Those diagnosed with severe and long-lasting anorexia have a mortality rate of 12.8% per year, the inquest found, compared to 2% amongst suspected cancer referrals.

Assistant coroner at the inquest, Sean Horstead, spoke of a lack of formal care and medical monitoring of patients with eating disorders in Essex, Suffolk, Bedfordshire and Hertfordshire.

The issue of medical monitoring has been an issue since before Miss Hart’s death in 2012, the inquest heard, and duties often fall to GPs. Cambridgeshire GPs have previously dismissed a proposal to assume monitoring responsibilities due to concerns including surgery capacity.

A new pilot scheme proposes low to moderate risk patients being monitored by specially-trained health care assistants, with those in the high risk category being monitored by the eating disorder service.

Earlier in October Dr James Stewart, author of an expert report, said that delays in consultations with dieticians and psychologists, the lack of keeping an official food log, and the failure to use a nasogastric tube to feed Miss Hart on her admission all contributed to her death.

The inquiry into Miss Hart’s death is one of five looking into how health services handle eating disorders. The inquests for Emma Brown (27), Amanda Bowles (45), Madeleine Wallace (18) and Maria Jakes (24) have already taken place.


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Jamie Hose

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October 2021
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