Sister’s plea to take anorexia seriously after 19-year-old student’s death left ‘big hole’
PUBLISHED: 05:30 09 November 2020 | UPDATED: 08:28 09 November 2020
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When Averil Hart died, she left a huge hole in her family – and was cruelly torn away from her parents and two sisters, Zoe and Imogen.
For Zoe, now 32, the scale of what went wrong in her sister’s case – which saw a coroner rule her death from anorexia was avoidable and contributed to by neglect – came as shock to her as she attended Averil’s inquest conclusion on Friday.
Nearly eight years on from losing Averil, a gifted student who died just 10 weeks into her first term at UEA, Zoe felt her inquest was a “triumph and a defeat all at once”.
“We obviously wanted to hear the truth and hear Averil’s death was preventable,” she said.
“It justified the work we’ve put into in getting to this point, but to have to sit and listen to it was obviously devastating.”
Assistant Cambridgeshire coroner Sean Horstead, who oversaw the separate inquests of anorexic women Maria Jakes, Emma Brown, Madeleine Wallace and Amanda Bowles, found seven failings by NHS organisations in their treatment of Averil.
At the Norfolk and Norwich University Hospital (NNUH), the coroner found “gross failure” to provide nutritional support amounted to neglect.
Bosses at the trust apologised “unreservedly” to the family.
For Zoe, Averil’s death in December 2012, after being rushed to NNUH and slipping into a coma from dangerously low blood sugar at Addenbrooke’s, came at a time when she was just leaving university – and hoping to explore the world with her sister.
Living in London at the time, it wasn’t long before she moved back to her home, near Sudbury, to be close to her mother, father and older sister.
“Averil and I were very close – and with my older sister Imogen as well – we did most things together, we were best friends, and spoke every day,” she said. “It leaves a big hole.”
Now well-versed in the failings which contributed to her sister’s death, Zoe feels it is vital others like her get the help they need.
“Young women and young men need to be taken a lot more seriously,” she said.
“With anorexia, it’s a deterioration of mental and physical state, so if you wait until that moment that the person is so gravely ill that they need hospitalisation, the mental health issues they suffer may have got to an almost irreversible stage.”
• Patients to benefit from new eating disorder service
Alongside her father, Nic Hart, Zoe said some good news came to the family on Friday when changes were announced to boost eating disorder treatment for adults in England.
NHS England has unveiled proposals to scale up a service offering rapid support to young people in the early stages of eating disorders such as anorexia and bulimia.
It is set to be rolled out in 18 areas – including Suffolk and north east Essex, two of the first to receive funding.
Mr Hart welcomed the new service, adding: “This will help to save lives and prevent other families having to suffer what we have suffered.”
The NHS’s head of mental health, Professor Tim Kendall, who gave evidence to Averil’s inquest, said the new service means teenagers or young adults who could benefit can be contacted within 48 hours - with treatment beginning as soon as two weeks later.
“Young people who are struggling with an eating disorder stand to benefit significantly with the rollout of this new NHS service,” he said.
“These services have already proven to be effective (through a 16-25 pilot in London) and the expansion in care we have announced will support our ambition to meet the rising demand for support to tackle young people’s ill health.”
More details are expected to emerge in due course.
• ‘When something goes wrong, you should get honest answers’
Frustrated by only achieving the truth through a seven-year fight for answers, Mr Hart also called for change in the way tragedies like his daughter’s death are handled by NHS trusts.
“When something goes wrong, you should get honest and quick answers, and from that, people can learn and make change. We shouldn’t be repeating the same mistakes time and time again,” he said.
“One thing that may not be obvious to others, but to families who go through this sort of thing, is that this has been seven years of my life - I haven’t been doing anything else.
“I haven’t run my company; I haven’t been able to stop. I’ve been awake most nights thinking about how we get to this point.
“It isn’t a minor thing, this can be truly devastating when the people you trust say ‘you’re wrong, this didn’t happen’, everything was satisfactory, go away.”
MORE: What we learned from the inquest of Averil Hart
In summing up Averil’s case on Friday, the coroner criticised witness statements provided by the Norfolk and Norwich Hospital in particular.
In one case, he went as far as to say a particular statement was “seriously misleading” with aspects of it “wholly inaccurate” in relation to Averil’s care.
The written statement claimed the need for immediate liaison with mental health teams was recognised; that ward staff had received guidance on how to treat Averil from a consultant psychiatrist; and that Averil had been closely monitored.
But it emerged in oral evidence that Averil had not been fed over four days, there was no weekend mental health support whatsoever, and no specific guidance had been provided to the ward.
Apologies were made for the inaccuracies while the trust itself said it was sorry for failings in Averil’s care.
Highlighting improvements made since, including 24/7 mental health support and eating disorder training for medics, NNUH medical director Professor Erika Denton said: “We acknowledge the devastating impact that Averil’s death has had on her family and we offer our sincere condolences for their loss.
“We recognise that the care and treatment we gave to Averil was not of the quality that we or our patients expect, for which we are very sorry and offer an unreserved apology.”
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