In addition to the recommendations to remedy the injustice Averil’s family suffered, we also consider there are wider lessons for the NHS from her case and the others set out in this report. To address these, we also make
the following recommendations:
- The General Medical Council should conduct a review of training for all junior doctors on eating disorders, informed by research being conducted by the Faculty of Eating Disorders at the Royal College of Psychiatrists;
- The Department of Health and NHS England (NHSE) should review the existing quality and availability of adult eating disorder services to achieve parity with child and adolescent services;
- The National Institute for Clinical Excellence (NICE) should consider including coordination as an element of their new Quality Standard for eating disorders;
- Health Education England should review how its current education and training can address the gaps in provision of eating disorder specialists we have identified. If necessary it should consider how the existing workforce can be further trained and used more innovatively to improve capacity. Health Education England should also look at how future workforce planning might support the increased provision of specialists in this field;
- Both NHS Improvement (NHSI) and NHS England (NHSE) have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries. NHSE and NHSI should use the forthcoming Serious Incident Framework review to clarify their respective oversight roles in relation to serious incident investigations. They should also set out what their role would be in circumstances like the Hart’s, where local bodies are failing to work together to establish what has happened and why, so that lessons can be learnt.