Coroner says death of anorexic student, 19, could have been avoided and was contributed to by neglect

A CORONER has said the death of an anorexic student could have been avoided and was contributed to by "neglect".

Averil Hart, 19, died a week after being found collapsed on the floor of her bedroom at the University of East Anglia in December 2012.

Averil, who was a black belt in karate and academically gifted, had started at the university in September of that year.

She had a three-year history of anorexia and had been discharged from the eating disorder unit at Addenbrooke's Hospital in Cambridge the previous month after an 11-month stay.

She lost weight during her first term and was taken to the Norfolk and Norwich University Hospital (NNUH) by ambulance after being found collapsed on December 7.

She was transferred to Addenbrooke's on December 11 and died there on December 15.

Cambridgeshire assistant coroner Sean Horstead has recently overseen a series of five separate inquests into the deaths of women with anorexia. 

After concluding Averil's inquest, the last of the five, he said that he would write to bodies including NHS England to raise a series of concerns.

Recording a narrative verdict in the case on Friday, Horstead said Averil's death "could have been avoided" but for a series of failings and "was contributed to by neglect".

He said the teenager was allocated to an "inexperienced trainee psychologist" amid a "staffing crisis" at the Norfolk Community Eating Disorder Service, and that an opportunity to intervene was missed when her father raised concerns about her condition more than a week before her death.

He also said there was a failure to provide "any appropriate nutritional support" to Averil during her four-day stay at the 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.


Speaking about the five inquests as a whole, Horstead said that the "absence of a formally commissioned monitoring service in primary or secondary care is the context wherein a number of these deaths have arisen".

He described the current situation as "something of a postcode lottery" and said he would write to NHS England with his concerns.

Speaking after Friday's hearing, Averil's father, Nic Hart, said: "We hope, now that the coroner has finally looked in detail at the evidence of the failings by each and every organisation looking after Averil, that there will be recognition of the urgent need for reform of the NHS eating disorder services not just in the east of England, but nationally, involving training and more resources."

Tracy Dowling, chief executive of Cambridgeshire and Peterborough NHS Foundation Trust, said: "We offer sincere condolences to Averil's family and we are very sorry for the shortcomings in her care.

"We have acted on the learnings from this tragedy and we continue to do so to advance the understanding and treatment of eating disorders, and together with our partners we are working more closely than ever on the provision of care for patients.

"We are committed to supporting further developments regionally and nationally which will ensure patients can access support at the earliest opportunity, and therefore have the best chances of recovery."  

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