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.
* 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 ?
* 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: