Ignoring the alarms: How NHS eating disorder services are failing patients

What happened to Averil Hart

Aged 18, Averil was voluntarily admitted to the Eating Disorders Unit in Cambridge on 19 September 20111. She had a three-year history of anorexia nervosa and a very low body mass index which meant there was a significant risk to her physical health. Over the following eleven months as an inpatient she slowly gained weight. 

Averil was very keen to take up a place at university in Norwich and doctors decided she could be discharged on 2 August 2012. She was still underweight and was referred to outpatient eating disorder services in Norfolk 
(the Eating Disorder Service) for ongoing treatment. This was to begin when Averil started university with a consultant clinical psychologist from the eating disorder unit providing therapy in the interim. 

Averil started her university course in September 2012. She was not allocated a care coordinator until October. She registered with the GP practice at the University of East Anglia Medical Centre (the practice). The GPs at the practice at the time were asked to monitor her medical condition weekly. 

Between 19 October and 23 November, Averil had six sessions with her new care coordinator (a psychologist) for cognitive behavioural therapy and weight monitoring. She saw a GP on three occasions between 12 October and 8 November. At the last appointment a locum GP told her she did not need to come back for a month. 

Mr Hart and Averil’s sister visited Averil at university on 28 November. They were shocked by how much weight she appeared to have lost and made an emergency call to the Eating Disorders Unit in Cambridge. As a result, a medical review with Averil’s care coordinator and a speciality doctor from the Eating Disorder Service was organised for 7 December. 

On the morning of 7 December Averil was found collapsed in her university room. She was taken by ambulance to the emergency department at the Norwich Acute Trust where she was admitted for three days. On 11 December Averil was transferred to the Cambridge Acute Trust. 

Overnight on 11-12 December Averil’s blood sugar fell to very low levels. She did not receive appropriate treatment for this and she became unconscious. She had suffered brain damage due to the low blood sugar levels. Tragically Averil died in hospital on 15 December 2012, aged 19. 

1 Addenbrooke’s Hospital is part of Cambridge University Hospitals NHS Foundation Trust, but the Eating Disorder Unit there is part of Cambridgeshire & Peterborough NHS Foundation Trust.