Foreword
I am laying this report before Parliament under section 14(4)(b) of the Health Service Commissioners Act 1993.
First of all, I want to thank Dr Bill Kirkup for leading this complex investigation with expertise, insight and independence.
We received a complaint from Mr Hart in 2014 about the care and treatment of his daughter, Averil Hart, who had anorexia nervosa and died on 15 December 2012, aged only 19. This was a serious complaint involving several NHS organisations. We took too long to complete the investigation and I sincerely apologise to Mr Hart and his family for the delay.
Our investigation found that Averil’s tragic death would have been avoided if the NHS had cared for her appropriately. Several NHS organisations missed opportunities to prevent the deterioration which led to her final admission to the hospital where she died.
We also 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.
Sadly these failures, and her family’s subsequent fight to get answers, are not unique. We have spoken to system leaders and experts in the field about the state of eating disorder services. What we have heard is reflected in the casework examples in this report.
In one case we investigated, a severely ill woman with suicidal thoughts was inappropriately discharged from hospital. Her care plan was inadequate and did not meet her care needs. As a result, nobody spotted the signs of deterioration in time and she died from a heart attack, triggered by starvation.
Another seriously ill woman with a history of vomiting and binge eating was referred to an Eating Disorder Service that was dangerously short-staffed. Again, there was no care plan in place and therapy sessions were inconsistent and unhelpful. Sadly, her condition deteriorated and she died of heart failure after taking an overdose, leaving a young child behind.
The families who brought their complaints to us have helped uncover serious issues that require national attention. Our report highlights five areas of focus to improve services:
1. The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders to improve understanding of these complex mental health conditions.
2. Health Education England (HEE) should review how its current education and training can address the gaps in provision of eating disorder specialists. If necessary HEE should consider how the existing workforce can be further trained and used more innovatively to improve capacity. It should also look at how future workforce planning might support the increased provision of specialists in this field.
3. The Department of Health and NHS England should review the existing quality and availability of adult eating disorderservices to achieve parity with child and adolescent services.
4. The National Institute for Clinical Excellence should consider including coordination in its new Quality Standard Ignoring the alarms: How NHS eating disorder services are failing patients for eating disorders to help bring about urgent improvements in this area.
5. Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and commissioners to conduct and learn from serious incident investigations. 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 where local NHS organisations are failing to work together to establish what has happened and why, so that lessons can be learnt.
Averil Hart’s case has important lessons for us too. We are currently in the process of developing our new three year strategy and the lessons from our handling of this case have informed some of my thinking in this area. In particular, I am determined to resolve complaints more quickly in the future so that important service improvements can happen without delay.
Rob Behrens, CBE
Parliamentary and Health Service
Ombudsman