- Video report by ITV News Correspondent Sejal Karia
A father of a teenage girl, who died following complications with her treatment for anorexia, has called for change across the NHS following a damning report that said the 19-year-old had been failed by every NHS organisation that cared for her.
Averil Hart's death in November 2012 was an "avoidable tragedy" the Parliamentary and Health Service Ombudsman (PHSO) ruled on Friday, but her father, Nic Hart, believes more needs to be done to prevent other lives being lost and to prevent the subsequent "cover-up" of the errors made by the NHS.
Averil was found unconscious on the floor of her student flat just four months after being discharged from an eating disorders clinic. She died eight days later from a heart attack.
The PHSO said Averil's death would have been prevented had the NHS provided appropriate care and treatment.
Averil's father, Nic Hart described the treatment of his "wonderful, bubbly, amazing daughter" as a "catalogue of disasters".
"You couldn't make up what happened in terms of the lack of care," Mr Hart told ITV News.
"It's hard to believe that so many mistakes could be made and those mistakes could happen (again) not just for someone with anorexia, but with any illness. That's why Averil's case actually matters to everyone and it's a case that should be brought to the attention of the NHS as a whole," he said.
Averil, from Sudbury in Suffolk, was voluntarily admitted to the Eating Disorders Unit in Cambridge aged 18 in September 2011.
She was discharged "too early" according to Mr Hart, in August 2012 to take up a place at the University of East Anglia after gaining five A stars in her A Levels, despite still being underweight.
Mr Hart said there was a huge gap in care once she left the unit.
"It was easy to see that Averil started to lose weight virtually from the day she left the inpatient unit... Everyone could see that she was unwell, but when we called for help, as a number of us did, no help was forthcoming.
"I went to see her in late November and was incredibly emotionally because I realised straight away how ill she was. She could hardly walk; she couldn't climb the stairs to her university flat - she had to sit every few steps.
"We all knew she was ill and yet the GP who saw her said 'I'll see you in four weeks'. But four weeks was too late. She was dead."
On the morning of 7 December Averil was found unconscious and taken to A&E at Norwich and Norfolk hospital where she declined further. She was then sent to Addenbrooke's Hospital where the prolonged admission process left her "basically dying" according to Mr Hart.
He said: "In the middle of the night... there was a mix up between the consultant and the junior doctor and they didn't give her the glucose that she needed. She became hypoglycemic and had a heart attack at that time and couldn't be resuscitated because she was so frail and had brain damage."
Averil died on 15 December 2012.
Mr Hart said: "In her 19 years, she lived as much probably as I've lived in my nearly 59 years. She knew how to live, have fun, sing in the rain. She was just a great girl."
The Parliamentary and Health Service Ombudsman report said: "Every NHS organisation involved in her care missed significant opportunities to prevent the tragedy unfolding at every stage of her illness from August 2012 to her death on December 15 2012.
"The subsequent responses to Averil's family were inadequate and served only to compound their distress."
But Mr Hart does not believe the findings go far enough. "I think what the report shows is that we need huge change in the NHS. You're asking each of these institutions - and bearing in mind there are four or five Trusts here - to be honest and open about what happened.
"The covers that happened - including deletion of emails, withholding medical records - this is not just not finding out about things, it's actively discouraging the trust from coming out.
"We need change at Trust level so these cover ups can't be part of their response, but we also need the ombudsman's office to actually to a proper job when they come to undertake an investigation.
"We've had 10 failed reports to get to this one, and the only reason this report's come out - because it's still full of holes, is because the Ombudsman has to appear before a select committee next week, so they've rushed this report out."
A Department of Health spokeswoman said: "We are introducing the first ever eating disorder waiting time standards and investing £150 million creating 70 new community eating disorder services across the country, so that no-one will have to go through the same ordeal as Averil."