Nearly eight years after the death of 19-year-old Averil Hart, assistant Cambridgeshire coroner Sean Horstead will on Friday deliver a conclusion in the month-long inquest into her case.
Mr Horstead is overseeing the separate inquests into the deaths of five women, including Averil, who died from eating disorders while under the care of Cambridgeshire and Peterborough NHS Foundation Trust.
Four of the inquests, into the deaths of Maria Jakes, Emma Brown, Madeleine Wallace and Amanda Bowles, have finished.
And for Averil’s family, who have spent years fighting for answers, there is a hope that Friday’s conclusion will prevent further tragedies.
Her dad Nic Hart said: “I hope that the coroner will reflect on Averil as a person.
“If you met her, you would have known a young person with an amazing mind and sense of humour, but someone who was fighting an illness on her own.
“She would quite often say ‘I can fight this’, but she didn’t have the help she needed.
“She was a real fighter and courageous. I feel that had Averil been properly looked after, she would have never ended up in hospital.
“I’d also like to see a reflection on how hard it is for anyone with anorexia to gain the services and treatment they need, and that the NHS needs to learn from mistakes in Averil’s case.”
MORE: Death of gifted student with anorexia ‘could have been avoided’, mother tells inquestAveril, a gifted pupil at Colchester Royal Grammar School, was from the village of Newton, near Sudbury.
In the summer of 2012, she was discharged from an inpatient unit for eating disorders at Addenbrooke’s Hospital in Cambridge – despite being considered at “high risk of relapse”.
The hearing was told of the 19-year-old’s wish to go to university that September.
But while at the University of East Anglia, Averil wrote in her diary – not seen until after her death – about falsifying her weight, describing how she became weaker and thinner as the anorexia took hold.
Just weeks into her first term, she was found collapsed by a cleaner and rushed to the Norfolk and Norwich University Hospital (NNUH).
While there, she fell and hit her head, before being transferred to Addenbrooke’s, where she slipped into a hypoglycaemic coma and suffered a heart attack. She died on December 15.
• Family tells coroner death ‘could have been avoided’
On the first day of the inquest, Averil’s mother Miranda Campbell said she felt her death was avoidable.
She questioned why professionals had not raised the alarm over her daughter’s decline, when Averil herself had recognised it in diary entries.
Dr Jane Shapleske, consultant psychiatrist at the inpatient unit Averil was discharged from in August 2012, described the teenager’s determination to go to university.She said Averil was deemed at high risk of relapse, but stressed there was “no pressure” for her to leave.
• ‘Staffing crisis’ meant vital checks were missed
The inquest also heard the eating disorder team Averil was referred into in Norfolk was experiencing a “severe staffing crisis”, which bosses fully acknowledged.
She had not been through the usual assessment clinic, the inquest heard, because of a “bespoke” arrangement where she was looked after by a psychologist and then the community team.
It meant she did not have blood tests for several months, which should have happened every fortnight.
• Hospital unit had ‘no mental health support’ over weekend
Dr Crawford Jamieson, then nutritional lead at NNUH, told the inquest the gastroenterology unit Averil was referred onto from A&E on Friday, December 7 would not have had any mental health support over the weekend.He said he recognised there was a need for “immediate liaison” with mental health teams.
But when questioned about support available, Dr Jamieson said it was only in place Monday-Friday.
Later on, Dr Charlotte Pither from NNUH said around-the-clock support is now in place.
• Gaps in support continue eight years on
Dr Jaco Serfontein, overseeing eating disorder treatment in the wider eastern region, said medical check-ups of patients considered low to moderate risk currently falls to GPs in several counties. If this is unavailable patients are escalated to a specialist service, he said, but in some areas like Essex, there is no dedicated psychiatric input.
When asked by the coroner if he felt there is an increased risk of future deaths without formally commissioned monitoring, Dr Serfontein said: “Yes, absolutely”.
Professor Tim Kendall, of NHS England, described a national push towards more formalised community support for eating disorder patients, with a focus on earlier intervention.
• Doctor warns of ‘national failures’ to protect patients
Senior GP Dr Katie Bramall-Stainer described continuing national failures to protect anorexia patients.
She said the national picture was “one of a failure to have a sustainable, safe, evidence-based, adequately commissioned position for patients to ensure long term positive outcomes”.
“I fail to understand, as a GP, how a developed nation in 2020 couldn’t be putting the requisite focus and resource and governance around this incredibly vulnerable and fragile cohort of patients who can relapse quickly and relapse seriously, with too often tragic outcomes,” she told the coroner.
• What happens now?
Once the coroner delivers his conclusion, he is also expected to draw up a prevention of future deaths report in the coming weeks.
This will set out action organisations need to take to prevent similar tragedies.
Averil’s father says the report is expected to encompass elements of all five cases the coroner has overseen relating to anorexia deaths in the east.
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