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 today.

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 Ombudsman.

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 two 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 in today’s 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 sessions.

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 unique.

‘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 five 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 services.
4. Better coordination of care between NHS organisations treating people with eating disorders.
5. National support for local NHS organisations to conduct and learn from serious incident investigations, particularly in circumstances involving several organisations.

Notes to Editors:

1. The Parliamentary and Health Service Ombudsman provides an independent and impartial complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. We look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. We share findings from our casework to help Parliament scrutinise public service providers and to help drive improvements in public services and complaint handling.
2. The Ombudsman’s investigation interviewed NHS staff who treated Averil and received expert advice from nine independent clinical advisers, including a consultant gastroenterologist, psychiatrists, GPs and nurses.
3. In a 2015 report on the costs of eating disordersOpens in a new window the charity BEAT estimates that more than 725,000 people in the UK are affected by an eating disorder.
4. Anorexia has the highest mortality rateOpens in a new window of any psychiatric disorder, from medical complications associated with the illness as well as suicide. Research has found that 20% of anorexia sufferers will die prematurely from their illness.
5. People with anorexia nervosaOpens in a new window often go to great lengths to hide their behaviour from family and friends and do not seek help. Once in treatment, it can take several years to fully recover and relapses are common. Treatment usually consists of a combination of psychological therapy and individually tailored advice on eating and nutrition to help the person gain weight safely. This is mostly delivered in an outpatient setting, but inpatient treatment can be recommended for very ill patients. Around half of people with anorexia nervosa will continue to have some level of eating problem despite treatment and, sadly, anorexia nervosa is one of the leading causes of mental health-related deaths.