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Averil Hart's death from anorexia could have been avoided, her mother tells inquest

Averil Hart
Averil Hart

The mother of anorexia victim Averil Hart has told a coroner that she believes her daughter’s death could have been prevented, questioning why clear signs of her physical deterioration did not “ring alarm bells” with medics.

Miranda Campbell described how she had cradled her “fiercely independent” 19-year-old daughter in her final moments as she died in intensive care in December 2012, saying that the pain of her loss meant that she still cried every day.

In written evidence to Miss Hart’s inquest, in Peterborough, Mrs Campbell listed a series of concerns over her medical care, including a lack of monitoring and specialist mental health provision in the months before her death.

The inquest is the fifth and final one of a series that have been linked by coroner Sean Horstead following allegations that they received insufficient care.

Miss Hart, Amanda Bowles, 45, Madeline Wallace, 18, Emma Brown, 27, and Maria Jakes, 24, were all under the care of Cambridge and Peterborough Foundation Trust (CPFT).

Diary entries recording Miss Hart’s decline, read out by Mr Horstead, documented her desperate battle against the eating disorder, which left her feeling exhausted and starving: “I can’t save myself,” she wrote. “I’m just not OK.”

Averil Hart
Averil Hart

Ms Campbell detailed her daughter’s medical care from when she was first admitted to the eating disorder unit at Addenbrooke's hospital, Cambridge, in September 2011, three years after she was diagnosed with anorexia, to her death in December 2012.

She said the teenager was “very frightened and scared” and found being on the ward “terrifying.”

She was discharged the following August, despite being “below her target weight” and feeling “anxious” about going home, Ms Campbell said. But the family was told her weight had plateaued in hospital and that “this was where the hard work really begins”.

“The staff knew that Averil was at a high risk of relapse and that her discharge would be an emotional time for her,” she added.

The family decided that Addenbrookes  should continue to facilitate Miss Hart’s care until she embarked on a creative writing course at the University of East Anglia, where it would be picked up by the Norfolk Community Eating Disorders Team (NCEDS).

However, many of the consultations were done by telephone, which “clearly did not allow a proper assessment of Averil’s weight and wellbeing,” Ms Campbell said.

“I am not aware that a doctor checked her heart or any other critical medical parameters at any time following her discharge,” she added.

Miss Hart was not allocated her NCEDS care co-ordinator, Vikki Powell, in Norwich for three weeks, and even then, her physical and mental health was not properly monitored, her mother said.

Diary entries, not available to family or clinicians at the time, reveal that she knew her condition was deteriorating and that the anorexia was “getting away with a lot”. In November, she wrote: “I can’t believe I’m still going.”

“If Averil could recognise this, how come Vikki Powell did not hear alarm bells?” Ms Campbell asked.

When Ms Powell went on holiday for two weeks, Miss Hart was left unsupervised, with no therapy sessions, her mother said.

She rapidly deteriorated and was rushed to hospital on December 7, 2012, when she collapsed.

Averil Hart with her father, Nic
Averil Hart with her father, Nic

However, she was placed on a gastroenterology ward, without specialist mental health provision, and was expected to choose food from a trolley, like other patients.

Despite being so weak she was unable to support her own head or swallow water, a consultant ruled out her detention under the Mental Health Act, the inquest heard.

Miss Hart died on December 15 after slipping in a hypoglycemic coma and suffering a bleed on the brain.

Mr Horstead, reading Ms Campbell’s evidence, said: “Concerns are expressed that the death, from her perspective, could have been avoided.

“These concerns make the loss even harder.”

The inquest, which is due to last four weeks, continues.