A 19-year-old girl Averil Hart died following a series of mistakes happened in organizations that cared for her. Hart was voluntarily admitted to the Eating Disorders Unit in Cambridge aged 18 in September 2011. She had a three-year history of anorexia and was severely underweight.
The Parliamentary and Health Service Ombudsman (PHSO) said as it warned of ‘widespread problems with adult eating disorders services in the NHS’, an organization to treat problem arise due to eating issues.
Its investigation found inadequate coordination and planning of the teenager’s care during a particularly vulnerable time in her life. There were also failures in her care and treatment in two acute trusts after she became seriously ill.
Over the following 11 months as an inpatient, she slowly gained weight and doctors decided she could be discharged in August 2012 as she was keen to take up a place at the University of East Anglia.But she remains still underweight.
She was referred to outpatient eating disorder services in Norfolk for ongoing treatment. But she was found unconscious on the floor of her student flat by a cleaner just four months later and transferred to a hospital in Cambridge, where her blood sugar was not properly monitored.
She died on December 15, 2012. The PHSO report said all the NHS organizations involved in the teenager’s care and treatment between her discharge from hospital on August 2, 2012, and her death failed her in some way.