Systemic failures in medical monitoring and neglect of hospital's care led to death of anorexic teenager Averil Hart from Sudbury, inquest concludes

Systemic failures around the medical monitoring for a teenager with anorexia nervosa, as well as neglect in her hospital care, contributed to her death, a coroner has concluded.

The inquest into Averil Hart, from Newton, near Sudbury, found multiple levels of her care were inadequate or inappropriate, and numerous opportunities to detect her decline were missed, prior to her death on December 15, 2012.

Recording a narrative conclusion at the closing hearing on Friday, following four weeks of evidence, assistant coroner for Cambridgeshire and Peterborough, Sean Horstead, said: "Averil's death could have been avoided."

Mr Horstead, who has overseen inquests into four other deaths from anorexia, stated the risk of future deaths from the disease remains, as gaps in the care framework for anorexic patients, as in Averil's case, are still widespread nationally.

He recorded seven key failings that contributed to Averil's death, following her discharge from the eating disorder unit at Addenbrooke's Hospital in Cambridge in August 2012, after 10 months as an inpatient, to attend the University of East Anglia (UEA).

The lack of a formally commissioned service to monitor her condition was deemed to have caused confusion between the UEA's medical centre and the Norfolk Community Eating Disorder Service (NCEDS), where she had been referred to.

Mr Horstead said this systemic shortcoming had impacted on the management of the 19-year-old's care and the response to the high risk of her anorexia relapsing.

In addition, a staffing crisis at NCEDS meant Averil was inappropriately allocated a trainee psychiatrist, whose inexperience dealing with anorexia was further compounded by a lack of appropriate support from the service team.

NCEDS was also deemed to have failed to directly engage with Averil's father, who raised concerns about his daughter's physical state after visiting her in late November 2012, resulting in a missed opportunity for an urgent medical review.

In early December, the creative writing student collapsed and was admitted to Norfolk and Norwich University Hospital (NNUH) – but Mr Horstead found multiple failings by NNUH over a four-day period that directly contributed to her death.

He determined the hospital failed to provide appropriate nutrition for Averil, did not provide adequate support from a dietitian or psychiatrist, and failed to manage her anorexic behaviour, concluding that NNUH's standard of care reached the level of neglect.

Finally, after Averil received an emergency transfer to Addenbrooke's, there was found to have been an unexplained delay in her being seen by a gastroenterologist.

However, Mr Horstead recorded that this was only a possible, rather than probable, contribution to hear death, due to her "greatly diminished chances of survival" following her time at NNUH.

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