A coroner has concluded that a Suffolk teenage's death from anorexia could have been avoided and was "contributed to by neglect" of health professionals.
Averil Hart, who was a student at the University of East Anglia, died eight years ago in Addenbrooke's Hospital after a catalogue of failings.
The coroner said her father had tried to raise the alarm but his concerns weren't acted on. The inquest was the last into five deaths of women from eating disorders while under the care of Cambridgeshire and Peterborough NHS Foundation Trust.
The coroner also said that the way anorexia is dealt with by the NHS is "not a safe system" adding it "gives rise to risk of future deaths."
Tracy Dowling, Chief Executive of Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), said:
“We are committed to supporting further developments regionally and nationally which will ensure patients can access support at the earliest opportunity, and therefore have the best chances of recovery.”
Averil was a gifted, popular and dynamic student but had been diagnosed with anorexia.
She'd been an inpatient at an eating disorder clinic at Addenbrooke's Hospital for 11 months when she left to join a creative writing course at the University of East Anglia.
The teenager from Newton near Sudbury lost weight during her first term and was found collapsed in her room in December 2012.
She died in hospital in Cambridge five days later.
The coroner listed six failings by various NHS settings - including lack of monitoring of a high risk patient by the UEA medical practice and Norfolk Community Eating Disorder Service which had a staffing crisis.
She was put under the care of a trainee psychologist who had no dealings with anorexia.
When her father visited her in November he was moved to tears how thin she was and contacted the inpatient unit at Addenbrooke's three times to ask for a medical review but she was never assessed.
When she was admitted to the Norfolk and Norwich University Hospital after collapsing, her chances of survival were greatly reduced because she was not given a feeding tube.
In a statement from the NNUH Medical Director Professor Erika Denton apologised saying she recognised "that the care and treatment we gave to Averil was not of the quality that we or our patients expect, for which we are very sorry and offer an unreserved apology."
She said that the Trust had taken steps to address issues raised by the coroner, by expanding its clinical nutrition team with expert consultants, nurses and dieticians, and providing additional specialist under-nutrition training for staff.
Then when she was transferred to Addenbrooke's there was a further critical delay as Averil wasn't seen by a consultant for nearly three hours.
Averil's father hopes that her death won't be in vain.
Meanwhile the NHS has today announced that it's to scale up an early intervention service to support young people in the early stages of eating disorders.
18 sites will we rolled out across the country - three in our region - in Essex, Suffolk and Bedfordshire.
Anyone affected by this story can contact Beat, an eating disorder charity, via their helpline on 0808 801 0677, or the Samaritans on 116 123.