Death of anorexic student ‘avoidable’ and contributed to by neglect, coroner rules
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The death of a 19-year-old with anorexia could have been avoided and was contributed to by neglect, a coroner has ruled.
Averil Hart, from Newton near Sudbury, lost weight during her first term at the University of East Anglia and died 10 weeks later in December 2012.
Assistant Cambridgeshire coroner Sean Horstead concluded an inquest into her death at Peterborough Town Hall on Friday.
He found there were “gross failures” in care provided by the Norfolk and Norwich University Hospital (NNUH), which amounted to neglect.
The coroner found the hospital had failed to provide any nutritional support.
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The teenager, diagnosed with anorexia in 2008, was rushed to NNUH on December 7, 2012, after collapsing.
She lost 14.5kg (2st 3lbs) in the four months since leaving inpatient services at Addenbrooke’s Hospital, a third of her body weight, and weighed 30.7kg (4st 11lbs) on admission.
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The inquest heard she had been asked to draw up her own food chart, which the coroner described as “absurd”, and to feed herself from the hospital trolley.
Deteriorating further over the next five days, she was transferred to Addenbrooke’s Hospital on blue lights where her chances of survival plummeted from 50% to below 20%.
Despite arriving at A&E she was not seen for five hours and miscommunication between medics meant her dangerously low blood sugar was not treated.
She slipped into a coma overnight and died on December 15, 2012.
Giving his conclusion after a month-long inquest, Mr Horstead said: “Averil Hart’s death could have been avoided and, on the basis identified at point 4 (relating to care at NNUH), her death was contributed to by neglect.”
Her medical cause of death was recorded as anorexia.
The coroner also said that, on the balance of probabilities, a series of “systemic and individual failings more than minimally contributed to the death”.
He said these included the lack of a commissioned service for the medical monitoring of an anorexia patient at high risk of relapse.
Averil was allocated to an “inexperienced trainee psychologist” amid a “staffing crisis” at the Norfolk Community Eating Disorder Service (NCEDS).
There was a “missed opportunity” when Averil’s father, Nic Hart, raised concerns about his daughter’s condition over a week before her collapse but was not spoken to directly by anyone at NCEDS, Mr Horstead said.
He said there was a failure to provide “any appropriate nutritional support” to Averil during her four-day stay at the Norfolk and Norwich University Hospital (NNUH).
“In the context of her severely malnourished condition recognised on admission, this was a gross failure which had a direct causal connection with, and more than minimally contributed to, her death,” he said.
“Averil Hart’s death was therefore contributed to by neglect.”
The coroner also outlined failures which he considered could possibly, rather than probably, contributed to her death, as her chances of survival had been greatly diminished on arrival at Addenbrooke’s.
• An unexplained four-hour delay before the consultant gastroenterologist was told about Averil arriving at Addenbrooke’s
• An eight-hour delay in being checked by a junior doctor and her bloods being taken at Addenbrooke’s Hospital, which led to a missed opportunity to start nasogastric (tube) feeding on December 11, and led to her hypoglycaemia being left untreated overnight.
‘Urgent’ need to address risk of future deaths
Mr Horstead, who oversaw the separate inquests of anorexic women Maria Jakes, Emma Brown, Madeleine Wallace and Amanda Bowles, is drawing up a prevention of future deaths report in relation to their deaths and Averil’s.
This will be sent to NHS England and will raise concerns echoed throughout all five inquests.
It will address gaps in community eating disorder care, which often sees medical check-ups on patients at moderate to severe risk of relapse carried out by GPs, in the absence of formally commissioned services.
He described a “lacuna” in support offered, and likened the gaps in current provision to a postcode lottery across the east.
In summing up Averil’s inquest, the coroner added: “I put on record now the urgency with which risk of future death, which I consider does continue, needs to be addressed.
“Reports, recommendations and reviews are no longer in my view sufficient to obviate the risk of future death, which I consider to be a real and immediate one.”
Anorexia has the highest mortality rate of any mental health illness, Mr Horstead added.
“There’s a hope that the tide can be turned,” he said.
“I hope the five inquests that have been heard in this jurisdiction can be the start of that in some small way.”
The coroner noted a “level of ignorance” of anorexia on behalf of health professionals, and intends to write to the Royal College of Psychiatrists, Royal College of Psychologists, and the General Medical Council to ensure medics receive training.
He is also writing to the ONS to ensure adequate recording of anorexia deaths.
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