Negligence at UEA Medical Centre
Following her move to university, the UEA Medical Centre became responsible for Averil's primary care. Averil’s care coordinator and staff at Addenbrooke’s S3 wrote to UEAMC before she started at University on two occasions. This correspondence states that Averil was of high risk of relapse and needed regular weekly check-ups to ensure her safety. A copy of the King’s College Guidelines for anorexic patients were also supplied as part of Averil's care plan.
A clear list of weekly (1-5 below) and bi-monthly (6-11 below) tests was drawn up. This table details the extent to which the instructions were adhered to by UEAMC. The first five columns represent the mandatory weekly tests, while the further columns represent the blood tests that should have been carried out.
Given that a number of the doctors at the UEAMC had already attended a specialist Anorexia Nervosa (AN) seminar provided by BEAT * (the eating disorder charity), it would be reasonable to expect that they fully appreciated that a high risk AN patient would require special attention, particularly as this was outlined in Averil’s discharge report from Addenbrooke’s, and in a further letter.
During the ten-week period between commencing university at UEA and her death, the UEAMC saw Averil on a very limited number of occasions and during these visits (which should have been weekly) they failed on many occasions to undertake even the basic health checks that had been required of them. They also failed to communicate with other agencies including the secondary care team, the Norfolk Community Eating Disorder Service (NCEDS) and the University disability service. These failures in patient safety were critical for Averil’s health and as a result she lost weight rapidly and her health quickly deteriorated.
Responding to our Complaints
NHS guidelines are clear in specifying that where a patient has died, that the NHS organisation involved must communicate with family in an open and honest manner.
As a family we wrote to the practice on numerous occasions to understand the causes of the tragedy. It soon became apparent that the UEAMC were being evasive and were particularly slow in responding to our correspondence, often ignoring the content of our letters or simply refusing to answer correspondence. This lack of disclosure was noted by the authors of CPFT's Serious Incident Report, and has affected all parties involved.
We feel that the UEAMC has been particularly obstructive with regard to an “open and honest approach”. NNCCG saw our concerns about this lack of openness and agreed to visit them. After this visit, we were informed that they had been advised by their medical defense union to remain “cautious in replying to our questions and not to provide potentially litigious information to us”. This has prevented us accurately establishing what happened in Averil's case.
While Norwich and Norfolk University Hospitals have been open, organising an independent investigation into their failures, UEA Medical Centre have hardly engaged with our communications, and much of the information we have derived from them has been obtained by other organisations on our behalf. Such an inability to communicate is unacceptable, and has prolonged the difficult process of working out what happened to Averil.