Negligence at NCEDS
In 2008, the death of Charlotte Robinson led to a review of eating disorders in the Norfolk area. Soon after, Cambridge and Peterborough NHS Foundation Trust was commissioned to provide the Norfolk Community Eating Disorder Service (NCEDS). The coroner's report which led to the change was strongly worded:
It is the intention of NHS Norfolk therefore to ensure that should, in the future, there be another incidence of fatality from an eating disorder that services were available and accessible to manage the eating disorder. It will not be acceptable for lack of services, or clinical expertise, to be contributing factors in any future inquest.
Our experience has shown that there has not been sufficient change in the region. Averil died due to a lack of clinical expertise, from an eating disorder, which, with the right treatment, should not have harmed her. This was the scenario that the Coroner had labelled unacceptable just four years before, and for which NCEDS should have been adequately prepared.
When Averil was transferred to NCEDS from S3 Ward at Addenbrooke's, there were significant gaps in the transitional care arrangements. While there was a handover meeting between S3 and NCEDS, this meeting was not adequately recorded. Moreover, Averil's family was not included in the process at all.
There was a significant delay between the point of discharge (2nd August) and her first appointment on the 19th of October, although her coordinator at Addenbrooke's was anxious for her to be picked up when a psychologist became available.
Once the transfer process had been 'completed', although checks had been mandated at UEA Medical Centre, no follow-up occurred to ensure that the care requested had been carried out, despite further communications between NCEDS and Averil's coordinator at S3.
Finally, the risk assessment that had been carried out was inadequate, failing to take into account the increased risk of relapse during a period of adjustment, both into university, and from one service to another.
Following her inpatient treatment at S3 ward, Addenbrooke's, Averil was referred to the NCEDS for secondary care as a high-risk patient, yet there was a significant delay (three weeks) between her referral, and her first meeting with her psychologist.
This psychologist, who started work at NCEDS in October 2012, had finished training only months before, and had not yet been registered with the HCPC. Averil, a patient at a high-risk of relapse, in a high-risk period of transition from inpatient care to outpatient care, was assigned to a newly qualified member of staff with no treatment record within NCEDS itself.
This lack of experience was exacerbated by a clear lack of supervision from those above her in the service itself and in particular the head of NCEDS Dr. Jane Shapleske.
Inadequate Supervision and Communication
While at S3, Averil's care was closely monitored, there is little evidence of supervision in Averil's case by those higher up in the service structure at NCEDS (above). It took four sessions before her clinical supervisor asked for a new care plan to be drawn up.
During the ten weeks she was at university, Averil's risk was apparently reclassified from high to low, of which there was no evidence on her medical records, and of which there has been no official confirmation from those involved in the investigation. Were such a decision to have been made, it is to be expected that there would be some official record of its having been taken.
Despite requiring regular physical tests to be taken by UEA Medical Centre, it appears that there was little communication with Averil's doctors there to ascertain whether these tests were being done, or what the results were. It appears, however, that Averil's psychologist asked the UEA MC to stop weighing Averil, and that weigh-ins would be carried out at NCEDS instead.
Besides this communication, no attempt appears to have been made to liaise with the UEA Medical Centre or to ascertain why insufficient tests had been carried out. When Averil's psychologist was unable to meet with her, she did not arrange for Averil to be weighed at UEA MC.
Failure to Respond to External Alarm Calls
When Averil's father and sister visited her at UEA in November, they were shocked to discover her condition. On telephoning NCEDS, they were reassured that action would be taken to check up on her. This never occurred, and Averil's psychologist was unavailable for her next appointment, leaving no cover arrangements, meaning that her further decline went unnoticed for another week.