Averil Hart, 19, was found collapsed in her university room after being let down by every part of the NHS supposed to help her eating disorder
The deaths of five women who suffered from eating disorders are set to be investigated by a coroner amid fears they may be linked to the care they received.
University student Averil Hart, who had anorexia, died aged 19 in December 2012, which an Ombudsman report described as an ‘avoidable tragedy’.
Her death and that of four other women – mother-of-one Amanda Bowles, 45, student Madeline Wallace, 18, Emma Brown, 27, and Maria Jakes, 24 – are now set to be investigated by a coroner.
All five women were reportedly under the care of Cambridge and Peterborough NHS Foundation Trust.
Sean Horstead, the assistant coroner for Cambridgeshire, who will preside over the inquests within the next few months, has said the ‘potential’ for themes common to one or more of the cases is ‘obvious’.
It follows a briefing report from earlier this year which looked at Norfolk Community Eating Disorders Service, managed by Cambridge and Peterborough NHS Foundation Trust.
The service was said to have had ‘significant difficulties’ recruiting specialists in treating eating disorders.
Last November, the trust raised its threshold for accepting referrals to only those with ‘severe’ eating disorders or in need of ‘priority’ treatment.
Miss Hart, who battled anorexia, lies in a hospital bed as her father Nic looks over her and he says the services are ‘worse than when [she] died, not better’
This decision was taken for safety reasons, as a high number of patients were said to be waiting ‘considerable periods of time between the assessment process and starting active treatment’.
Miss Hart was let down by four NHS bodies, according to the Parliamentary and Health Service Ombudsman.
The former grammar school pupil was found collapsed in her university room after losing two stones – nearly a third of her body weight – in less than three months.
The Ombudsman said that there was not a robust or explicit enough plan from the trust about giving warning signs if Miss Hart deteriorated and what action was to be taken if that happened.
It also held the trust responsible – as it oversaw Norfolk Community Eating Disorders Service – for failure to ensure ‘adequate surveillance’ which would have spotted that her condition had deteriorated.
Miss Hart’s father, Nic Hart, said that his daughter’s NHS care had been ‘third world’, stating: ‘They left a high-risk patient to fend for herself.’
Doctors had not properly tracked Miss Hart’s (pictured, as a young girl) weight or her mental health during her anorexia, a Parliamentary and Health Service Ombudsman found
Speaking two years ago, Mr Hart said: ‘It’s pretty clear to us that there have been systemic failings. Services are worse than when Averil died, not better.’
The four other women died between September 2017 and September 2018.
The father of Emma Brown, Simon Brown, 56, said: ‘Clinicians, GPs, private institutions… it carries on all the way through.
‘In short, there is a massive failure in the system to deal with this illness and people are dying as a consequence.’
He said it was the ‘sincerest hope’ of himself and Emma’s mother, Jay, that the inquest would provide knowledge to ‘prevent similar suffering and death in other young people’.
Nadine Dorries, the mental health minister, said: ‘The NHS is learning from times it has previously failed patients and, following avoidable tragedies, we have made great strides in transforming the nation’s mental health services.
Mental Health minister Nadine Dorries has vowed to do ‘all [she] can’ to see ‘real change’ in the help available for people struggling with eating disorders to prevent any more tragic cases (pictured is Miss Hart who died in 2012)
‘While progress has been made, I’m not so naive as to not realise we still have a long way to go to ensure no one struggling with an eating disorder slips through the net.
‘I vow to do all I can to ensure we see real change towards helping people to ultimately lead healthier and happier lives.’
Pre-inquest review hearings have been heard for each of the five cases.
A spokesman for Cambridge and Peterborough NHS Foundation Trust told the Sunday Telegraph that the death of any patient was a ‘tragedy’.
But the spokesman added that, at the recent pre-inquest hearings, the coroner had yet to make ‘findings, determinations or conclusions with respect to any of the five inquests – let alone with regard to any definitive links between them.’
Timeline of the girl’s deaths
December 2012 – Death of Averil Hart, Addenbrooke’s Hospital
September 2017 – Death of Amanda Bowles in Cambridge
December 2017 – Parliamentary and Health Service Ombudsman (PHSO) report Ignoring the alarms: How NHS eating disorder services are failing patients, into the death of Averil Hart and two others known as Miss B and Miss E is published
March 2018 – Death of Madeline Wallace, Peterborough City Hospital
August 2018 – Death of Emma Brown, Cambourne, Cambs
September 2018 – Death of Maria Jakes, Addenbrookes Hospital
June 2019 – Public administration and constitutional affairs committee (PACAC) report published
August 2019 – Government response published
September 2019 – Pre-inquest hearings