'Substantial failures' in handling of father's complaint into Suffolk teen's death, report finds
PUBLISHED: 16:34 10 January 2020 | UPDATED: 12:58 11 January 2020
'Substantial failures' have been made in the handling of a complaint into a Suffolk teenager's death, an investigation has revealed.
The Parliamentary and Health Service Ombudsman (PHSO) has apologised to the family of Averil Hart for a "number of failings" revealed in a report published on Thursday, January 9.
University of East Anglia student Averil, who lived with anorexia and was cared for by the Cambridgeshire and Peterborough NHS Foundation Trust, was 19 when she collapsed in her student flat on December 7, 2012.
After being rushed to hospital with a dangerously low temperature, blood sugar and blood pressure, the creative writing student from Newton, died on December 15.
Her father Nic issued a complaint to the PHSO in 2014 and received a reply in 2017, when the organisation's investigation found every single NHS organisation involved in her care had failed.
The ombudsman has since reviewed its handling of Mr Hart's complaint, and has said there were "substantial failings" in the way it was handled - but significant improvements have been made in their way of handling complaints since.
The report found the organisation would have expected to close a similar case in half of the time it took to handle the complaint as there "was not a clear and consistent plan in place to resource the investigation".
Five caseworkers worked on the case at different times, which led to Mr Hart frequently having to re-tell his story, which the ombudsman admitted "made it hard" for him to "build and maintain trust in PHSO".
It also found Mr Hart had received "mixed and sometimes contradictory messages" about the investigation while failing to clearly explain how evidence was being used, while senior managers made commitments that were not kept, or in some cases "should not have been made".
In a statement on behalf of the family, Mr Hart said: "Averil's death was totally avoidable and she was failed by all of those who were responsible for her care.
"Following this her family were failed by the ombudsman, at great personal cost, and during a time when they should have been allowed to grieve.
"Our hearts go out to those who have been similarly failed both in the NHS and also at the PHSO."
An inquest into Miss Hart's death is due to open in March.