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NHS criticised by ombudsman over death of teenager from anorexia

Averil with her father in hospital Credit: Averil's family

The death of a teenager from Suffolk from anorexia could have been avoided according to an ombudsman's report.

19-year-old Averil Hart died in 2012. A report by the Parliamentary and Health Service Ombudsman says it followed a series of failures that involved every NHS organisation that cared for her.

The report says there are widespread problems in the NHS treating adults with eating disorders.

The Ombudsman investigation found inadequate coordination and planning of Averil's care during a particularly vulnerable time in her life, when she was leaving home to go to university.

There were also failures in her care and treatment in two acute trusts when she was seriously ill.

"What should have been put in place was a team that would look at her mental and physical well being, what happened was that because the community eating disorder service in Norfolk was understaffed she was put under the care of a trainee and that trainee as we found out had no experience of anorexia at all so she didn't recognise the fact that Averil was slipping away and that she was becoming dangerously ill. The GPs who should have seen her on a weekly basis only saw her 3 or 4 times, and the last time they saw her when they should have been doing blood and other checks the locum said we'll see you in a month and of course Averil was dead by then."

– Nic Hart, Averil's father
Averil Hart Credit: Averil's family

Averil died just before her 20th birthday weighing little more than 4 and a half stone.

The report highlights five areas of focus to improve eating disorder services:

  • Training for all junior doctors on eating disorders to improve understanding of these complex mental health conditions
  • Greater provision of eating disorder specialists.
  • Adult eating disorder services to achieve parity with child and adolescent services.
  • Better coordination of care between NHS organisations treating people with eating disorders
  • National support for local NHS organisations to conduct and learn from serious incident investigations, particularly in circumstances involving several organisations.

'Averil's tragic death would have been avoided if the NHS had cared for her appropriately. Sadly, these failures, and her family's subsequent fight to get answers, are not unique. The families who brought their complaints to us have helped uncover serious issues that require urgent national attention - I hope that our recommendations will mean that no other family will go through the same ordeal.'

– Parliamentary and Health Service Ombudsman Rob Behrens

We met Averil's family in 2014 to offer our sincere condolences for their sad and devastating loss. Since then we have taken into account the learning from this tragic event and our structure and processes have been reviewed. Across the Trust, there is greater awareness and recognition of the issues associated with eating disorders. The Trust would like to repeat the apologies previously made to Averil Hart's family and accepts the findings and recommendations in the Ombudsman's report."

– Norfolk and Norwich University Hospitals NHS Foundation Trust

"When Averil was transferred to Addenbrooke's in December 2012, she was already very unwell but her death, at that time, may have been avoided had failures in her care not taken place. A thorough investigation has been carried out, lessons have been learned from what happened to Averil and a number of changes made. We will be writing to Mr Hart to outline the changes which have been made since this tragic event, as recommended by the ombudsman."

– Cambridge University Hospital

Council accused of 'ruining Christmas'

A council in Essex has been accused of ruining Christmas after ordering a festive attraction to close down over safety fears.

  • Serena Sandhu visited the attraction and sent us this report.

The Christmas Wonderland in Clacton-on-Sea comes with a Santa's grotto and train rides, but unfortunately no planning permission.

It's proved so popular the council says the local roads can't cope with the increase in traffic. But the event organisers are determined to stay open.


Warning to elderly drivers

Warning to elderly drivers Credit: ITV Anglia

Police in the region are warning elderly drivers to ensure they're fit to drive, following an increase in the number of accidents involving people over 70.

They say poor eyesight and underlying medical conditions such as dementia are driving the problem, as is an ageing population .

Finding water leaks: Ancient crafts v modern technology

The amount of water being lost through leaking pipes is on the increase.

Anglian Water say they're using the latest technology to track leaks down, while there are others like professional water diviner John Baker still using old fashioned methods

John Baker Credit: ITV Anglia
  • Overall leaks are up by 1.2% over the last year
  • Essex and Suffolk Water has seen leaks increase by 9.1%
  • Cambridge Water's leaks are up 8.2%
  • The average person uses 141 litres of water a day

"Let's face it nothing's cheaper than a pair of bent rods, it's not going to tax the water companies is it, put their profits in jeopardy."

– John Baker, Professional water diviner

John Baker admits he can't explain how his divining works. However Anglian Water says it only uses modern technology to find leaking pipes.

Technology Anglian Water uses to find leaks Credit: ITV Anglia

"Anglian Water doesn't use dowsing rods or divination, we don't issue them to our staff, we use scientific based technologies like listening sticks which are a stick which can hear leaks in water pipes and make a hissing noise, we also use digital versions and also thermal imaging drones to find leaks in our pipes."

– Sarah Dobson, Anglian Water
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