Anorexic UEA student's death linked with four other cases
PUBLISHED: 16:51 21 May 2019 | UPDATED: 16:51 21 May 2019
Four deaths of patients with eating disorders are being linked to failings surrounding a 19-year-old Norwich student, a coroner's email has revealed.
Averil Hart, from Sudbury, suffered with anorexia, and collapsed in her student flat at the University of East Anglia on December 7, 2012.
She was rushed to hospital with a dangerously low temperature, blood sugar and blood pressure - but it was three days before medics realised the seriousness of her illness.
Doctors transferred her to Addenbrooke's Hospital in Cambridge on December 11 - but she was not seen for five hours. She died on December 15, suffering a heart attack and brain damage from the low blood sugar.
Her father Nic Hart has since campaigned for changes for those with eating disorders, and Averil's case was a key part of a Parliamentary Ombudsman report which was released in December 2017 and found every single NHS organisation involved in her care had failed. It demanded widespread changes to be made countrywide.
Now, Mr Hart has been told by Cambridgeshire senior coroner David Hemings that his daughter's inquest, which has not yet taken place, is "inextricably linked" to four other inquests concerning Cambridge and Peterborough Foundation Trust (CPFT), the organisation which runs Norfolk Community Eating Disorder Service (NCEDS) for adults across Norfolk, except Great Yarmouth and Waveney.
In the email, seen by this newspaper, Mr Hemings said: "As you aware, the tragic death of Averil is linked to four other eating disorder deaths that we are investigating."
You may also want to watch:
He said a serious incident report had be received in one case, but work was still ongoing in at least one other.
He said: "The pace of those other matters is inevitably having an impact on progress of the investigation of Averil. I thought I should advise you of the current position because the next PIRH [pre-inquest review hearing] date for the inquest of Averil is inextricably linked/entwined with these other major investigations."
Mr Hart said: "It shows the level of concern, there have not been the improvements we've all been hoping for."
Tracy Dowling, CPFT chief executive, said there were five cases awaiting inquests in Cambridgeshire which included a diagnosis of an eating disorder - one from 2012, one from 2017, and three from 2018.
But she said: "It should also be noted that at the pre-inquest review hearing in September 2018 the Coroner emphasised that 'no findings, conclusions or determinations of any kind had been reached during the course of any of the coronial investigations to date and that there is nothing more than the potential for the possibility of a common theme or themes to arise'."
A spokesman for the Norfolk and Norwich University Hospital added: "Our sincere condolences go out to Averil's family for their loss.
"We met with the family following Averil's death and we have taken into account the learning from this tragic event and many of our structures and processes have been reviewed, changed and updated.
"Our nutrition support team has been expanded and now includes three consultant staff, and we have embedded MARSIPAN guidance into trust policy. Across the trust, there is now greater awareness and recognition of the issues associated with eating disorders."