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