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Blog

Time to publish the entire record of Averil's death and the cover up by the NHS trusts involved.

Nic Hart

In the near future the Ombudsman plans to publish its failed report into Averil's death and lay it before parliament.

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Rob Behrens the Ombudsman has decided on a timetable that does not seem to allow for any time for re-investigation of the failed inquiry that was undertaken nearly three years ago. This early inquiry was undertaken by incompetent PHSO staff who simply did not understand what had happened to Averil and why she had died.  For three years we have battled to try and ensure that the Ombudsman's office review their failed reports, but sadly although there have been some minor improvements, there are still numerous errors in the latest draft.

Naturally if the Ombudsman publishes a report that does not truly reflect the events surrounding Averil's death. A report that gives no idea of accountability or of the cover up by the NHS trusts involved, then we will start the process of a judicial review to call for a full re-investigation. A new inquiry to show exactly what happened and why Averil died and how she was failed by the NHS clinicians involved. 

In addition to this we will then have the right to publish the Ombudsman's report nationally and allow all interested parties to view all of the documents including the internal emails that show exactly what happened to Averil and the cover up that ensued as well as how the PHSO investigation failed.

I know with a certainty that the truth will come out, just as certainly as the tide that washes the beach where we walked with Averil when she was alive.

Nic 30th June '17

A trainee psychologist was appointed as Averil's care co-ordinator and sole clinician, she went on holiday and left Averil to die.

Nic Hart

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If a vulnerable young person with a dangerous mental health disorder like Anorexia is to survive and remain healthy whilst at University, they require the specialist care that is outlined in their care plan.

It also makes sense that the care coordinator and clinician looking after the patient has some experience of the NHS, adequate supervision and some in depth experience of the patient's illness.

In Averi's case the care coordinator assigned to Averil by Dr. Jane Shapleske was a trainee with no experience of Averil's illness. The NCEDS team provided no meaningful care for Averil and left Averil to die when the trainee went on holiday with no cover in place.

After more than a 1000 days of investigation, the Ombudsman fails to tackle this crucial element of Averil's care and fails to provide any accountability whatsoever.

Is it any wonder that it took 25 years for the Hillsborough families to get the truth and get justice when the establishment closes ranks in this way including the Ombudsman.

Time for the Hillsborough Law to have real teeth and shake the tree until the truth comes out.

Nic 29/06/2017

Open message to Rob Behrens - Death of Averil Hart aged 19

Nic Hart

After 1046 days of investigation by the Public and Health Service Ombudsman into Averil's death which has involved the resignation of five investigators and multiple failed draft reports we have been given just a few days to highlight the failings of the current draft which contains 871 sections. Many of these sections contain serious factual errors and do not reflect the truth about what happened to Averil or the cover up by the clinicians and NHS trusts after Averil's death.

Put simply Averil starved to death.

Averil's death was caused by the negligence of the Norfolk Community Eating Disorder Service, with the only clinician looking after Averil (who was a trainee with no experience of eating disorders) going on holiday without cover ..... leaving Averil to die.

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 Open message to Rob Behrens the Ombudsman.

 

Dear Rob,

 

When we spoke on the phone recently I don't think I had a real chance to truly convey to you my sense of the opportunity that lies before us right now. 

This is an opportunity to make a difference to many patients that currently need help.

I have dedicated the past four and half years since Averil died to ensuring that the truth about the care that she received is known and that it is out there for all to see, so that things improve for others. It would have been only too easy for me to leave Averil's funeral and feel that nothing could bring her back. That I should start grieving for her right there and then. 

Instead I have put my grief and my life on hold.

When Mark Taylor of the NNCCG told me that Averil's care was 'satisfactory', as did Aidan Thomas CE of CPFT, Anna Dougdale CE of NNUH, Keith McNeal CE of Addenbrooke's and Dr. Edwards of the UEAMC as well as those from NHS England, I simply could not accept their word that Averil's had been cared for properly. 

This was because I knew with total certainty, that the lack of NHS care had totally failed a wonderful person and caused Averil's death.

Averil helped so many people when she was alive. She was courageous in fighting her illness and even in her darkest moments she gave optimism to others and helped them to live.  I simply could not just leave Averil's coffin without picking up the banner of that courage and start fighting for those in a similar situation.

After two years of fighting for the truth, It would have then been easy when the investigators at the PHSO, firstly Alessandro Pulzone and then Russsel Barr and later Sarah Fox told me that Averil's death was a result of hospital negligence. I could have said that I had done enough because we had made "a little progress".

But I knew that Averil was failed where she lived, not just where she died. She was a vulnerable young person and was failed at University, by those appointed to carry out her care plan.

At this point I took a deep breath and with those that have helped me, we continued to fight to ensure that the Ombudsman's report was a true reflection of what had happened.

To this end we continued to provide evidence and work to show the Ombudsman exactly where the failures had occurred.

So here we are, after four and a half years of meetings, emails, travel to all corners of the UK.  We have spoken to those involved with Averil at University, those who are specialists in the care of AN patients, charities, the scientific community and also to bereaved families and those whose daughters and sons are still being failed and may die in the months to come. This knowledge has given us incredible resources to fight for the truth and for improved care.

Fortunately, I have been blessed not only by Averil's courage, but also by the help and fortitude of some amazing people who are working behind the scenes on every aspect of Averil's case.

Those that have helped me include Averil's mother Miranda, who has worked in medical publishing all her life for the Lancet, Pulse and Medicine International. My sister Cleo who is a senior consultant Psychiatrist, her husband Bernie who has spent his life in Medicines Sans Frontieres and working as a GP with specialism in patient safety. Three interns, Henry Cooksey, Kate Vango and Rob Chinnery with legal and medical backgrounds. Behind the scenes we have been helped by whistleblowers who know Addenbrookes and CPFT from within. Last, but not least, we have been helped by Katherine Murphy, who has stood shoulder to shoulder with us at every single meeting ensuring that Averil's tragedy is not lost in the corridors of NHS bearocracy.

Since Averil died, all of these individuals have given their utmost to help and continue to do so on a daily basis. Together we have a knowledge base of the illness as well as the care that Averil received which amounts to more than ten years of work.

Sadly this has not been matched by PHSO, whose work on Averil's case has often been sporadic and ill informed by poor investigative techniques. Sadly the "dedicated" investigator(s) and resources we were promised at the first meeting have never materialised in any meaningful way.

So maybe Rob you can start to understand that when I got your message to say that you were personally going to take charge of the inquiry into Averil's death, that I felt a huge sense of relief and hope.

The "Hope" was that you would want everything in the report to be a true reflection of what happened to Averil. Not just relying on a few worthwhile recommendations to paper over the cracks of a poor investigation, but a robust report that does not shy away from showing exactly what happened to Averil and the cover-up by CPFT and others.

The NHS trusts involved have continued, even to the present day, to spend money on legal fees in protecting their reputation whilst still claiming that Averil's care was satisfactory. Sadly they have spent little time or resources to investigate thoroughly what happened or to make the changes that are required to improve patient safety. We estimate that the combined spend on defence of the indefensible has cost the NHS over half a million pounds so far. In the meantime the PHSO shy away from looking back to see where their own investigation failed in the early stages, seemingly hanging on to the idea that expert opinions that were based on poor evidence are still valid.

Please therefore take a moment to understand where we are and what we still have to do.

I feel that we are close to generating a worthwhile report, but that we must pull together to make it across that thin line which will allow the whole truth to be published bravely with the courage that Averil possessed. 

It is nearly time for me to start grieving for my wonderful daughter Averil, but before I do so, we need to do more work to create a report that truly reflects the circumstances behind Averil's untimely death.

Nic

Averils dad

contact@averilhart.com

www.averilhart.com

http://www.averilhart.com/blog/

@averilsdad

#justice4averil

 

Who has control ? Communication in the NHS.

Nic Hart

Averil wanted to stay with her big sister at Nottingham Uni for a few days and so on a sunny day in October we flew from our home airstrip in Suffolk to Nottingham.

As usual she wanted to be in charge of the music, handing out the sweets and also wanted to fly the plane. 

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Averil had been flying with me locally before, but this was the first time that she had a chance to take the controls for a long flight, so I gave her the customary induction when flying with someone new. 

I'll give you control and you confirm and tell me you "you have control"

Averil looked at me as if to say "whatever dad" and with a rye smile told me that as usual she was "in control". 

Averil flew perfectly and smoothly. She flew around the clouds and over the fens covered in a thin layer of mist, around the military bases north of Peterborough along rivers and across the many quarries and fields and finally over the ridge north of Cottesmore that signifies that we were a few miles from the airport. She then handed back control to me and smiling she reminded me to say that I "have control" and we landed softly at Nottingham airfield.

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Tragically Averil is only in spirit with me now when I go flying.

Averil died from Anorexia Nervosa just ten weeks after starting University and she died without the care that she so badly needed.

The care she received was split between primary and secondary care. The secondary care to provide the expertise and overall coordination and the primary care to monitor her basic health parameters. Tragically the primary care team failed to monitor Averil's physical condition regularly and the secondary team care coordinator had no experience of Anorexia.

Amazingly there was no communication between the two NHS organisations during the ten weeks that it took for Averil to literally starve to death. The care coordinator went on holiday without cover and the last GP to see Averil told her to come back in 4 weeks - by which time Averil had died.

Expert opinion seems split as to who was responsible for communicating with whom and about what.

However, it is clear to me that the "crash" that killed Averil occurred because of the lack of communication between the teams involved and within each team. Despite Averil being a high risk patient, no one was clear on Averil's physical health and it appears that each of the organisations was relying on the other for vital checks that simply weren't carried out.

Two further failures in communication occurred.

Once when we called for help after seeing Averil who could barely walk and were told that the secondary team would take action but didn't act in time and secondly when a further failure of communications happened when Averil arrived at the acute ward after being found unconscious in her flat . Tragically there was a mix up between a junior doctor and the consulant which resulted in Averil's blood sugars falling to critical levels such that she suffered a heart attack and later died.

When I am asked why Averil died I reflect on her illness and her care.

Averil had a treatable condition and the care was available - so to me it was a total failure of communication that resulted in Averil's tragic death. 

Multi crew cooperation and communication is key to flying safely as well as getting the sweets and music you want when you are flying with your daughter.

It is also the key to keeping a vulnerable young patient safe. 

Nic  

Averil's dad

 

Cover up .. The sad truth

Nic Hart

How does an NHS organisation cover up negligence and the death of a young person ? 

They use power and influence to hide the truth. 

Below is yet another chilling example of how this has happened in Averil's case. 

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Recipe for Death

Nic Hart

Four years after Averil died we know what happened. The perfect recipe for NHS failure.

Take a young, vulnerable patient suffering from a high risk illness like anorexia, away from her home to study at University. 

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*   Place her in the hands of an organisation like Cambridge and Peterborough NHS trust that have a five million pound contract to provide community Eating Disorder care (NCEDS).  

* Place her in the hands of a trust run by Aidan Thomas. A man who left his last position in the NHS after he cut 500 mental health jobs, who has families paid off and who spends vast amounts on lawyers to protect CPFT's reputation rather than learn from the avoidable deaths of patients. 

*   Arrange for the team at NCEDS to be run part time by a clinician like Dr. Shapleske that appears to place career above care. This clinician will allow Averil to be discharged under her target weight, into a Community Eating Disorder Unit run by Shapleske that is understaffed and that is unable to provide the care that she needs. 

*  Understaff that team to save money. Employ trainees who have no experience of Anorexia Nervosa and appoint them as the sole clinician to care for high risk patients like Averil. Give that same trainee with no NHS experience the pivotal roles of care co-ordinator for a vulnerable patient. Even basic skills like calculation of BMI will not be carried out correctly. 

*  Fail to provide adequate supervision of this trainee. 

* Allow that trainee to go on holiday and arrange no cover so that the high risk patient becomes dangerously ill.  So seriously ill that her words are slurred, she has oedema and she can hardly stand because of lack of nutrition.

* Provide a GP practice that carries out the four basic checks on only one occasion, completely ignoring her care plan. They will fail to arrange ECG and blood tests and stop the weekly visits all together with a note stating - "review in a month". 

* Fail to respond when the patient's family raises the alarm to the lead clinician, Dr Shapleske refuses to take the call even though she is the only point of contact that the father has. 

* When the young vulnerable girl is so ill that she is unable to climb the stairs to her flat and the cleaner makes an emergency call to the university, send an unqualified carer to see her and fail to call for medical help.

*  When she is found unconscious two days later, take her to Norfolk and Norwich hospital. A hospital that will fail to treat her illness and waste two days expecting her to feed herself.  Miss the opportunity to save her life and then send her to another hospital. 

*  When she arrives by emergency ambulance at Addenbrookes hospital create a mix up so that she is left dying for six hours before being seen by the consultant.

*  Allocate the dying patient to Dr Woodward a consulant who has a mix up with his junior doctor in the night so that the patients blood sugars drop to a critical level and the patient has a heart attack and suffers brain damage.

*  Provide a bank nurse from the geriatric ward to care for a dying patient leaving her parents to provide all her care. 

*   Lastly, leave the patient in the care of some amazing nurses that provide 24/7 care for Averil with her family around her for several days until she dies. Leaving her family bereft and heartbroken.

                                                         **********************************

Tomorrow is the anniversary of Averil's death, the day I sat and held my daughters hand as she took her last breath.

Averil didn't have to die, she had a curable illness. She simply needed proper care from the NHS and from those clinicians looking after her.

After Averil died the lead clinician of NCEDS Dr. Shapleske, the CE of CPFT Aidan Thomas, the CE of NNCCG Mark Taylor, the CE of Addenbrookes hospital Dr. Keith McNeal all told us during face to face meetings that Averil's care was "satisfactory". If this was the case, how did a 19 year old girl suffering from a curable illness die within ten weeks ?

Is it any surprise that these individuals are resposible for creating a recipe within their organisations for further tragedy and death of vulnerable patients ?

The Health Ombudsman's draft report into Averil's death already condemns the service failures that occurred in all of these organisations. So will Shapleske, Thomas, Taylor and McNeal now conveniently change their minds and say that their organisations let Averil down and that they were "responsible for Averil's death" ?

Only time will tell. But there have been no signs during our meetings with them of their humanity towards Averil or her family, they have simply allowed us to suffer for four years with absolutely no compassion.

What would an apology from any of these individuals actually mean ? Would it simply be more political posturing from them in order to remain in their jobs and keep on with business as usual with more deaths to follow ?

Nic 14/12/2016

*  Postscript

*  Repeat this perfect storm for other patients.

*  Allow the NHS trusts to investigate themselves - and cover up what happened, by destroying emails, "concocting a plan" and employing legal teams to protect the clinicians.

*  Give the NHS Ombudsman a chance to investigate all of the trusts, with 5 investigators resigning and  spend two and a half years overlooking basic facts, so that there is no timely learning and so that other young lives remain at risk. Sadly, the PHSO is not fit for purpose and therefore there is no end to this torment in sight. 

*  We are not alone. The CQC published a report this week about the Learning, Candour and Accountability of the NHS. It reviews the way NHS Trusts review & investigate the deaths of patients in England, documenting how many families are suffering at the hands of the NHS. To read more, please go here: 

http://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf

 

 

 

Averil died when ....

Nic Hart

Averil died when she was just 19 years old - she was hit by the "drunk driver" that was the NHS in chaos. 

Next week it will be four years since Averil died.

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The drivers that were at the wheel of the NHS during that fateful 10 weeks, then destroyed the medical record, covered up the crash scene and "concocted" a plan to escape detection. The police that investigated the scene of the accident were the PHSO and they didn't even ask the driver if they had had a drink ?

So the lead clinician, the trainee who left Averil to starve to death in the community and the consultant at the hospital where there was a mix up that resulted in Averil having a heart attack are all still out there and keeping a low profile protected by NHS lawyers.

What the cheif executives at the NHS trusts don't appear to realise as they spend money on lawyers to protect their reputation, is that the truth is slowly being revealed.

It has always been out there and at some point in the future it will return and overcome the years of lies and cover up.

You can not destroy the truth of how and why Averil died - it is there for all time. 

The last three and a half years has been utterly soul destroying for Averil's family. How do you grieve for someone you love, when you read and write reports on their death every day ?

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Next week it will be four years since Averil died.

I will go to the field where we have planted Christmas trees for her. I will tell her that I am still fighting for the truth and that I will keep fighting with her courage until the world knows what happened and that she didn't need to die.

It is in the hope that no other family will have to ever have to go through this.

I will tell Averil how much I miss and love her and that I am with her.

Nic 08/12/2016

Look into your soul and tell the truth.

Nic Hart

 

I'll die with a broken heart, but sometimes it feels worse to live with the pain and sorrow whilst people lie and cover up Averil's death.

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Delete your emails, concoct plans to protect your reputation, withhold information and medical records, but .......

In the end, you who were responsible for the death of a beautiful young girl, know what happened and you know that Averil didn't have to die. If only you had done what you should have done.

It is time that you looked deep into your souls and time that you did the right thing.

Tell the truth, tell someone that can make a difference to the past and to someone's future safety.

Nic 15/11/2016

 

"Lest they be forgotten ..."

Nic Hart

Averil died when NCEDS and the medical centre at the UEA failed in their duty of care. 

In our opinion they were grossly negligent and allowed Averil to die without the help she needed and then tried to cover up what happened. 

http://middlegroundmusings.com/in-memory/

http://middlegroundmusings.com/in-memory/

Our aim has been to uncover the truth behind Averil's death and also try to ensure that other patients are not left to die in similar circumstances. 

Sadly since Averil's death, we have been contacted by other patients and families who have found themselves in similar circumstances and have been left near death and without treatment or help. 

To those that are helping us to fight for better care for all of those with AN or ED's - Thank you and let all of us remember those that died struggling to stay alive without the NHS help that they and we all deserve.

Nic 07/11/2016

Please honour all of those who fought an ED with courage.

http://middlegroundmusings.com/in-memory/ 

What would Averil be doing today if she was still with us ...

Nic Hart

It's been raining in the night and It's still warm outside.

This morning I sat on the beach watching the birds feeding on the wet sand and thought about life since Averil died.

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Life has been in limbo, a blur of daily emotional turmoil as we fight to get the NHS to admit what happened to Averil and try to come to terms with her loss. Trying to ensure that we live up to the courage that she showed as she fought her illness, totally without help from those that were supposed to be caring for her.

Maybe because its that time of year when we all think towards our plans for Christmas and arrange to meet family and friends but I couldn't help but start thinking about Averil's birthday on the 21st of December. So close to the day that we died .. The 15th of December.

Yes, I mean we died, because that it is how it often feels. We died that day.

Thoughts flit like the seabirds above the waves to what Averil would have been doing right now ...  It's early morning, about breakfast time.

Averil would have been 23 now, she would have finished her degree in creative writing and maybe she would be living in Edinburgh with Alex. I spoke to him yesterday, he said it was cold and very autumnal, and we talked of the views around the castle and the wonderful colours.

Averil may have had a career in journalism or some form of creative endeavour. I am sure she would have called her sisters today to see how they were and catch up on life, she would have been in touch with her many friends and spent time thinking about us all. 

Averil loved quirky clothes, colours and art, so she would have enjoyed dressing for the weather, dressing for the day ahead. Maybe she would have had a rushed breakfast of Croissants and coffee just as I did this morning. And maybe she would have called me and said "how you doing dada" just as she always did.

However her day would have started, Averil would have given so much to all us. 

Life will never be the same without her. 

Nic 12/10/2016

Why the Ombudsman's failure puts patients lives at risk ...

Nic Hart

 

THE CONSEQUENCES OF PHSO FAILURE - MORE AVOIDABLE DEATHS

Here is a copy of our recent correspondence with Dr. Bill Kirkup, who is heading the Ombudsman's failed inquiry into Averil's death.

784 days into the inquiry and with the resignation of 5 investigators.

We are still so far from the Truth that it hurts. 

 

1.        On 6 Oct 2016, at 16:13, Bill Kirkup wrote:

"Dear Nic,

I am sorry once again to be apologising, and do understand that this is an exceptionally frustrating process.  It has taken longer than I expected to bring everyone somewhere near the same page since Sarah left...........

With apologies,

Bill"

 

2.      On the 7th Oct 2016, Nic Hart wrote:

 Dear Bill, 

You will no doubt appreciate, that whilst the Ombudsman continues to fail, there is little chance of true NHS improvement in cases like Averil's and therefore the same mistakes continue to be made.

This places patients at risk. 

My concern, along with those of other families, is that as a result of the continued failings by the Ombudsman, more patients will die unnecessarily.

We all need the PHSO to wake up fast and take on its responsibilities to those at risk in society right now.

Nic

Averil's dad

 

 3.      On the 7th Oct 2016, Nic Hart wrote:

Dear Bill,

Yet again.

Further delays.

Where are the resources that we were promised two and a half years ago in order to get the inquiry into Averil's death completed within 12 months ?

I am sorry to have to say this to you quite so directly.

The PHSO is a failed organisation and appears to care very little for those it is supposed to be helping.

You say that this is a "frustrating process" for Averil's family as though we are waiting for a delayed train. 

What Julie Mellor and others fail to understand is that every day that passes without proper resolution of the inquiry into Averil's death, is a day that causes us real pain and real suffering. 

We are in touch with other patients and families whose cases are being dealt with by the PHSO and we are not alone. 

The Ombudsman is creating further injustice to those that have already suffered terrible loss.

Regards,

Nic Hart

Averil's dad

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Putting Together the Pieces...

Nic Hart

After Averil died it took a little while to piece together what had happened. It was obvious in the beginning, as we rushed from A&E unit to A&E unit, that the hospitals that were meant to be looking after her didn't know what they were doing. They were unable to care effectively for Averil, missing several opportunities to save her life.

But the full extent of the tragedy only became clear in the weeks, months and years that followed.

At Averil's funeral I tried to convey to everyone the courage that Averil had shown. Leaving S3, moving away from her family, starting university... all the while suffering with Anorexia and being without the care that the NHS should have provided by the NHS that was failing her and that ultimately allowed her to get so weak that she couldn't even climb the stairs to her room.

It slowly became apparent that Averil had not received ANY care at all in the two weeks before she died.

Her trainee Care Co-ordinator had simply gone on holiday and no effective cover had been arranged. The lead clinician of the community care unit (NCEDS), had not even seen fit to take appropriate action when Averil's family called to let her know that Averil was seriously ill and that she required urgent care.

They simply left Averil to die.

There was no communication between the Norfolk Community Eating Disorder unit and the GP surgery on the University of East Anglia campus and the doctors simply told Averil that they "would see her in a month", by which time Averil had died.

SO WHAT DOES NHS FAILURE look like ?

NHS failure looks like a young girl dying of treatable illness due to their lack of care.

It looks like chaos, well paid clinicians doing nothing to save a young person’s life and then covering up the mess to retain their jobs and their reputation.

It looks like the lead clinician at NCEDS, deleting emails and holding back Averil's medical records from her family for nearly two years whilst emailing others to try and prevent Averil's anonymous case study being published.

It looks like the author of MARSIPAN Guidelines for the management of really sick patients with anorexia nervosa, caving in to external pressure and removing Averil's case study from the latest edition of MARSIPAN in order to "protect the reputation' of the NHS trust involved.

It looks like the lead consultant at Addenbrooke’s telling Averil's family not to tie themselves up in knots wondering "why" Averil died, knowing all along that his mix up with the Junior Doctor in the middle of the night had caused Averil to become hypoglycaemic and suffer a heart attack.

It looks like five officials dealing with Averil's investigation at the NHS Ombudsman resigning one after the other and producing poor quality reports that do not reveal the true NHS mess that allowed Averil to die.

It looks like the Ombudsman telling us that they believe that clinicians are lying in Averil's case but refusing to investigate the cover up that occurred.

And sadly it looks the NHS’ lack of concern for the safety of their patients in the future....... Parents continue to contact us to tell us they are experiencing terrible care for their loved ones, many of which are in a similar situation to Averil, even after all that has happened.
 

Nic 14/09/2016

When simple things break your heart ......

Nic Hart

When Averil died we were left inconsolable.

Those that were supposed to care for Averil and were responsible for her death received counselling , whilst Averil's family and friends were left with an ongoing battle for the truth and a hole in our hearts that will never heal.

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Three and a half years on and the pain is just as real and the memories flood back.

Something as simple as a glass of water in my hand can bring back memories of being at Averil's side as she died in hospital, where it was hot and dry and we needed to keep her lips moist.

Even eating a grape can make me wonder whether the fruit in my own mouth would have been enough to keep Averil alive the night she had a heart attack. This was the night when the junior doctor and consultant had a mix up and failed to keep Averil's blood sugars monitored and safe.

Nothing will bring Averil back to us, but working daily for the truth and trying to prevent another similar tragedy does bring me strength.  Just seeing Averil's pictures makes me smile and think of the wonderful times that we had and the joy that she brought to all of our lives.

Nic 07/08/2016

 

 

 

 

Why Averil's Death Matters to Everyone...

Nic Hart

Why Averil's death matters to everyone...

When there are failures and negligence in the NHS that lead to someone's death, it is tragic and we feel a great sense of loss, but we hope that there will be learning in order to improve NHS care so that nobody else will die in the same circumstances.

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In Averil's case some of the clinicians have tried to cover up what happened and have written internal emails about the "..potential reputational damage to the service and trust". They deleted emails, they briefed staff on what to say before outside interviews were held, they managed to get Averil's case study removed from a national safety publication (MARSIPAN), they also withheld patient records… The list goes on. All the while making the search for the truth about what happened to Averil all the more difficult.

In what world is it acceptable to put the reputation of a hospital over the life of a young woman and the safety of others ?

The cover up of any death is a terrible thing, but sadly it seems to be part of NHS culture.

Mid Staffordshire, Southern Healthcare, Morecambe bay are all examples of the NHS protecting their own rather than learning from mistakes and improving.

 

This matters to all of us.

Averil's death and the deaths of all those who have been subject to NHS ‘service failure’, will affect all of us in some way, at some point. This is because every family will need the NHS at some stage in their lives and it is essential that we can trust the clinicians to do what’s best for the patients they are caring for and learn from previous mistakes in order to keep patients safe.

And right now we need the Ombudsman to investigate the evidence, gather the truth and create a report that truly reflects what happened.

Why go to the Ombudsman with your Complaint .... ?

Nic Hart

Why go to the Ombudsman with your complaint ... ?

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Many families get in touch through Averil's web site or via Twitter. The web site details our fight to expose the NHS negligence that led to Averil's death.

Often there is a familiar story.  

Once a family's complaint has been held in limbo by the NHS trust involved for a year or two and lies dormant in the proverbial NHS waiting room, there are two simple choices; either you simply "give up" or you take your complaint to the Ombudsman.

The full title of the Ombudsman is the Parliamentary and Health Service Ombudsman (PHSO), and perhaps from this name one can expect that the members of parliament who oversee this institution will ensure that it does a good job at representing those that have suffered or have been failed by the NHS.

But don't be fooled by the fancy name, our experience is that the PHSO is an organisation that is not fit for purpose and sadly those who run NHS trusts knows this and act accordingly.

It is hardly surprising therefore that the NHS organisations that were responsible for Averil's death do not concern themselves with the outcome of the Ombudsman's inquiry. In fact as Keith McNeal, the Chief Executive at Addenbrookes hospital (where Averil died) said to us .. "who are the Ombudsman ? ".

When we originally arrived at the Ombudsman's door we were promised a speedy, in-depth investigation into Averil's death and a final report to be laid before parliament within 12 months. 

Two years on, following a lot of pressure and help from the Patients Association, we finally have a draft report from the Ombudsman.  But it's a report that fails in nearly every respect. One hundred pages of excuses for what happened in Averil's tragedy and yet so far from the revealing the true negligence that occurred.

There appears to be no accountability whatsoever and even when the Ombudsman knows that clinicians are lying, they refuse to investigate "wrong doing".

In many ways, by refusing to investigate these lies and the cover up of Averil's death, the Ombudsman becomes part of the lie, complicit in the wrong doing and responsible in no small part for the failure of the NHS to improve its care for some of the most vulnerable people in society.

A lost opportunity and a reflection on how the "establishment" protects itself when someone dies as a result of NHS negligence.

The Ombudsman's office has been under the spot light a lot recently for a multitude of high profile failings and virtually everyone who has been involved in the investigation into Averil's death has resigned. 

One by one ....... Allesandro Pulszone, Russel Barr, Mick Martin, Dame Julie Mellor - have all gone and sadly we are still at a draft report stage. In summary a complete disaster.

Last week, I spoke to a mother whose daughter died in similar circumstances to Averil to see how her complaint was progressing. The local NHS trust had covered up her daughter's death in much the same way by destroying the evidence. She told me that she was in the process of taking her complaint to the Ombudsman, but having read the recent bad press about the way that they had handled complaints and the also recent resignations, she wondered if it was worth the grief to her daughter's family.

So why go to the Ombudsman with your complaint ? 

There's no simple answer to this - but if we don't fight for the truth and for a better system to investigate failures in the NHS, then how will we ever get a better society, better NHS and most importantly better care for our loved ones.

My advice was to try. 

But in trying, know that the system is badly broken and that you will have to fight every step of the way for the truth. You will probably have to do most or all of the work yourself and provide all of the evidence rather than rely on the "investigation" that takes place. Do not take their competence for granted and be aware that when you enter that concrete tower in London you may find, as we have, that sadly there is a black hole with little compassion, understanding or competence to investigate.

Our experience is that the Ombudsman is a failed and broken institution, where complaints and evidence get lost for months, if not years - and the result appears to be a watered down report that normally lets the NHS establishment continue business as usual, even when they have been responsible for a young person's death. There is no sense of accountability whatsoever.

The only real checks and balances on the Ombudsman are made by the persistence of families themselves and the charities like the Patients Association.  

But still we live in hope, that just like Hillsborough, the truth will come out ....... and IT IS worth fighting for.

Nic 09/08/2016

PS. For the record don't forget to tape all of the meetings that you have with the Ombudsman and ask for transcripts if they record them. Undoubtedly you will need them.

 

 

Where We Are Right Now...

Nic Hart

We began Averil’s campaign in order to prevent the tragedy of her death ever being repeated. But to also help raise awareness of the illness, its treatment and how those suffering from it are cared for. 

Day to day we are making slow and steady progress with these aims, but we always need more help.

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Recently, I was interviewed by Suzy Powell (working with the HSIB) about Averil's death and I was asked about the circumstances in which she died and the way her death was subsequently handled by those organisations that failed her.  

To answer simply, not only did those who were meant to be caring for Averil fail her but those who had the ability to provide answers to her family failed her also. 

Investigation teams within the NHS organisations have proven to us that they are unable to produce truly independent reports that shed true light on the failings of their own organisations.

This highlights the need for a robust investigation team that can look into deaths and serious incidents from a truly independent standpoint.

We have faith in the fact that the truth surrounding Averil's death and the cover up that ensued will come out, but until then we can only work towards spreading Averil’s story in ways such as this interview. 

http://www.averilhart.com/interview/ 

Please take the time to watch our video, comment and spread the word that we need truthful investigations into serious incidents and we want better services and care for our loved ones in the community.

More opportunities to help ..

Nic Hart

Thank you for the overwhelming response from the talk in Manchester on patient safety and thank you also to all of those who have emailed or tweeted me to pass their sympathy to Averil's family.

It is reassuring to know that so many proffessionals and patients are totally dismayed and horrified by the care that Averil received from Addenbrooke's, CPFT and the UEA medical centre.

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Please make a difference to all of those that you contact by letting them know about Averil's case so that we can prevent a tragedy like this happening again.

To all of those that asked for more information, I will be publishing all of the facts once the PHSO report has been sent to parliament. Sadly it makes for very sad reading and it is hard to believe how the care that Averil received was worse than in the third world. 

Please sign up in the contact section if you would like to see each of the final reports on the care that Averil received. 

If you have a patient safety conference and would like me to talk about Averil's case then please contact me. 

Nic 14/07/2015

Manchester Patient Safety - Thank You.

Nic Hart

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Thank you to Professor Stephen Campbell and the team for inviting me to talk about Averil's Life and lack of care that she received from Cambridge and Peterborough FT and the University of East Anglia Medical Centre.

I hope that the lessons learned from Averil's tragedy will be spread amongst GP's and health professionals and improve their knowledge of caring for those with AN.

I also hope that all those that have heard about the cover-up of the negligence involved will share our story and be able to help us to reveal the truth in the coming months.

 

Patient Safety in Primary Care: A Shared Responsibility is Wednesday at 1:30 PM

Organized by NIHR Greater Manchester PSTRC

A story of NHS failure.

Nic Hart

Yesterday, I was told about this presentation, put together by Luca Cadrillo, which analyses Averil’s case from an academic perspective.

A story of Failed teamwork.

It is heartening to see that Averil’s tragedy is being used by others to learn, and to ensure future patients benefit from greater understanding of where care can go wrong. There is no shame in learning from mistakes.

Tomorrow, I am continuing to encourage such learning by meeting the All Party Parliamentary Group for Patient and Public Involvement in Health and Social Care. Alongside others with similar experiences, I will be explaining how the NHS trusts involved in Averil's care allowed her to die without the care that she so badly needed and how they have failed to learn from Averil's tragedy.