In 2017, our Ignoring the alarms insight report included the tragic case of Averil Hart, who had anorexia and died in 2012 aged only 19. Our investigation found that NHS organisations missed vital opportunities to prevent her death.
The families who brought their complaints to us helped uncover serious failings in NHS care for people living with eating disorders. Our report made five recommendations to prevent the same mistakes happening again.
The Public Administration and Constitutional Affairs Committee (PACAC) published the its inquiry into the findings of our report.
The Government response to PACAC’s report committed to making improvements to eating disorder services a priority and a fundamental part of its work to improve mental health services. The response also noted the progress already made on improving eating disorder services since publication of our report and reiterated the Government’s commitment to implementing its recommendations.
More recently the coroner’s report into Averil Hart’s death and the separate inquests of four anorexic patients urged action to address failings in eating disorder services and to prevent further avoidable deaths. It’s vital that our report’s recommendations are fully implemented to prevent future failings.