In early December 2011, when Averil was an inpatient at Addenbrooke's ward S3, Averil's family were invited to attend a series of family days at Douglas House in Cambridge.
These family days were held with Dr. Sarah Beglin and Madeline Tatham, key members of the care teams that failed Averil when she so badly needed help.
Two of the families attending shared graphically their concerns that their daughters had experienced "near misses" after leaving hospital and when living in the community, and as a consequence these patients had ended up in acute wards and a very poor mental and physical condition as a result of the lack of care.
To say that this was just a general discussion on "care in the community" would be untrue.
This discussion was central to one of the daily sessions and was extremely emotional for the families and patients involved. As such I would have hoped, as we all did, that NCEDS and S3 would have taken notice of these sad events, the lack of care and the risks involved when young vulnerable patients are left without support in the community.
These concerns were met with little understanding by SB and MT and they told all at the family day that "a new regime" was now in place and all would be well.
This "new regime" sadly was the one that we experienced with terrible consequences.
Little did we appreciate at the time on that cold December day that these concerns were so very real and that they would would result in Averil's death.
Little did we understand on that cold day, that the new team at NCEDS would be so disorganised and incapable of looking after high risk patients in the community that they would allow a young person to die alone at University without help.
I hope that those involved in the "coffee mornings and family days" will now find time to reflect on the real world and the very real care that young patients need .....
...... especially when these young patients are alone in the world and their lives are hanging in the balance.