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Nic Hart

When I first met with NNCCG over a year ago (the commissioners of the comunity care team that looked after Averil), they were keen that any lessons learned from Averil's tragedy would help them to implement change and protect other AN sufferers arriving at hospital acute wards.

We discussed how I would be involved in meeting with clinicians to explain what went wrong with Averil's care and how implementation of MARSIPAN would enable safe gaurds to be put in place to protect AN sufferers. 

Like many promises made along the way over the past 18 months the NHS haven't even implemented this simple action plan.

At a further meeting with the chief executive at CPFT I was promised an "independent external review" of Averil's case and this offer was made in writing. This has never happened. 

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