The Ombudsman's Report
Please click on the links below to download both PHSO reports looking into Averil's death, either the Insight Report, entitled "Ignoring the alarms: How NHS eating disorder services are failing patients", or the full 167-page investigation report.
Complaint Against the Parliamentary and Health Service Ombudsman (PHSO)
Our original complaint submission to the PHSO.
Complaint Against Norwich and Norfolk
University Hospital (NNUH)
Averil arrived by emergency 999 ambulance at the Norwich and Norfolk University Hospital after being found unconscious in her university flat by the cleaner.
The hospital failed to appropriately treat her illness and this lead to a serious deterioration in her health at a time when she was already critically ill. As a result of the failures at the NNUH, Averil was then transferred to Addenbrooke's emergency ward in an attempt to save her life.
Our complaint to NNUH detailed the failings of the hospital in caring for Averil at a critical stage. We subsequently received a letter from the chief executive Anna Dugdale, who gave a series of excuses for the failures, citing hospital medical records. There was no apology for the failings and no proper responses to a series of important questions.
Note : To those making complaints to NHS organisations following serious incidents:
NHS organisations routinely use medical notes by way of defence, these notes often (as in Averil's case) only reflect a very skewed and subjective version of the truth.
In Averil's case she was expected by the hospital to feed herself from the ward trolley which is unthinkable for a MARSIPAN patient. The NNNUH defence to our complaint suggests that the medical records state that "Averil had a yoghurt each day", however, this is far from our experience of the actual events.
Averil also fell when moving around the ward and sustained a serious head injury, when proper treatment would require a critically ill Anorexic patient of 30kg to be monitored and supported at all times.
The SI report by CPFT clearly states that "Averil's medical records did not reach the standards expected" and this appears to be the case with NNUH too and leaves many questions unanswered.
Complaint Against UEA Medical Centre
When a young person is discharged from hospital to go to University, the hospital routinely sends the University GP practice a discharge letter with medical notes.
In this case Addenbrooke's S3 ward sent a letter to the University with accompanying notes that clearly stated that Averil was at "high risk of relapse". Given that Averil had nearly died in 2011 when she was admitted to the hospital this "High Risk warning" was a clear indication of the specialist care that Averil needed from her primary care GP team.
The discharge notes from S3 request that the GP practice check Averil's weight, blood pressure, heart rate and other parameters weekly.
A number of the GP's at the University of East Anglia Medical Centre had already received training on awareness and risks associated with Anorexia Nervosa from the main UK charity BEAT.
Averil attended an initial meeting with the UEA medical centre and the notes on her file show that they were aware of the high level of risk. The notes made by the medical centre itself clearly state that "...this is a dangerous time for Averil".
Unbelievably despite all of these warnings signs the UEAMC failed miserably in their duty to look after Averil. In the ten weeks at University the UEAMC only saw Averil three times and failed to properly check her health during this period. For this we hold the UEAMC doctors responsible in equal measure (with NCEDS) for Averil's death.
Dowload our complaint to NHS England which clearly shows the chaos and Negligence shown by UEAMC, Dr. Edmonds and colleagues.
Complaint Against Addenbrooke's S3
Transitional periods are well known to be a high risk time for patients transferring from one service to another, especially young patients like Averil who are about to start a new life at University after several months in hospital. At such times the role of the care coordinator is critical to ensure that High Risk patients are cared for appropriately to reduce the risk of relapse.
In this case the care coordinator from Addenbrooke's S3 Dr, Sarah Beglin appears to have failed to ensure Averil's safety during this transition period in numerous ways which are detailed in our complaint. To date this complaint has been "bounced" on a technicality by CPFT (in their efforts to hide the truth) and they say that Averil's BMI was marginally over the MARSIPAN threshold when she was transferred between services. Given the tragic outcome this type of rebuttal shows clearly that those concerned have failed to learn the lessons of Averil's death.
We will be resubmitting our complaint in a format (with reference to other guidelines on patient safety) which does not allow the Trust to escape from their dereliction of duty and their negligence in looking after a high risk patient during a period of transition.
Our Submission to CPFT's "Serious Incident" Report Team (22nd March 2013)
Supervision of CPFT and NCEDS by NNCCG
In May, we attended a meeting with North Norfolk Clinical Commissioning Group, asking detailed questions about their provision of care, and their responses were revealing. In the absence of a direct complaint, they do not appear to carry out any independent checks on the provision of care. Over several years, millions of pounds has been spent without any form of quality control.
See our questions and their responses here:
Documents from Other Organisations
Patients Association: Patient Stories (2013)
Each year, the Patients Association puts together a collection of stories of treatment within the NHS. Calling it "one of the most tumultuous periods in the history of the NHS", they suggest that each case could have been avoided, and that, for that reason, the Government should re-consider its position on cuts to the NHS.
Robert Francis: The Inquiry into the Mid-
Staffordshire NHS Trust
Following a series of cases where patients in the Mid Staffordshire NHS trust suffered while under their care, Sir Robert Francis unveiled a culture focused on targets, rather than patients, and a focus on positive information at the expense of grave concerns shared by many. Significant reforms were urged.
The Marsipan Guidelines
The "Management of Really Sick Patients with Anorexia Nervosa" guidelines, prepared by the Royal College of Psychiatrists, were prepared by Dr. Paul Robinson and an experienced team. They are designed to prevent avoidable deaths of anorexia patients when admitted to general hospital wards.