The deaths of five women with eating disorders are being linked by a coroner following warnings of a growing crisis over the way anorexia sufferers are treated within the NHS.
All five, four of whom died within a year of each other, were under the care of Cambridge and Peterborough Foundation Trust (CPFT), leading to allegations that their deaths were “completely avoidable”.
The death of one of the women, Averil Hart, 19, in December 2012, prompted a Parliamentary and Health Service Ombudsman (PHSO) report that described her death as an "avoidable tragedy" that could have been prevented.
Now the trust is facing further scrutiny after a coroner decided to investigate her death alongside those of mother-of-one Amanda Bowles, 45, student Madeline Wallace, 18, Emma Brown, 27, and Maria Jakes, 24.
All of them died between September 2017 and 2018. Sean Horstead, assistant coroner for Cambridgeshire, will hear the inquests within the next few months and has noted that the “potential” for themes common to one or more of the cases is “obvious”.
A Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) briefing report published in April, noted that the local eating disorder service for adults had experienced “significant difficulties” in recruiting staff, meaning that the threshold for referrals was raised.
Patients awaiting treatment at the time, some of whom were deemed “priority” cases, were simply given a podcast which gave advice.
Nic Hart, Averil’s father, who has campaigned tirelessly for justice, has warned that patients are continuing to die as a direct result of NHS failure. “It’s pretty clear to us that there have been systemic failings,” he told the Sunday Telegraph.
“Services are worse than when Averil died, not better.”
Simon Brown, 56, Emma’s father, claimed there were many ways that his daughter was let down by the system.
“Clinicians, GPs, private institutions… it carries on all the way through,” he told the Telegraph. “We had to overcome difficulties caused by those that should have been trying to help her.
“In short, there is a massive failure in the system to deal with this illness and people are dying as a consequence.”
He said it was the “sincerest hope” of both himself and Emma’s mother, Jay, that some insight may come from her inquest that can “prevent similar suffering and death in other young people.”
The ombudsman report into Ms Hart's death, titled Ignoring the alarms: How NHS eating disorder services are failing patients, was the first to shine a light on concerns over the Trust's care into patients with eating disorders.
It concluded that every single NHS organisation involved in her care had failed her in some way when it was published in December 2017.
The report made five wider recommendations relating to the improvement of eating disorder treatment nationwide, but a Commons report published 18 months later, in June, said insufficient progress had been made.
The public administration and constitutional affairs committee (PACAC) report warned there was a “serious lack of training” for doctors about eating disorders, amounting to little more than “a couple of hours”.
It called on the General Medical Council to make junior doctors complete a four month psychiatry placement, including clinical experience in eating disorders. It also found the dearth of precise information about the prevalence of eating disorders to be “shocking”, while the quality of care was described as a “postcode lottery”.
Patients were being discharged when they reached a certain weight, with no guarantee their mental health had recovered. Both reports highlighted the discrepancies between children’s eating disorder services and those for adults, which are vastly under resourced.
The transfer between the two can also pose risks.
Sir Bernard Jenkin MP, PACAC chairman, warned the government needed to adopt a “sense of urgency” to stop the problem and that the NHS must learn from its mistakes.
“We cannot risk any more avoidable deaths from eating disorders,” he added.
Pre-inquest hearings have been heard for each of the five cases over the last fortnight. The Trust has spent £90,000 on legal fees in defending its reputation so far, according to a Freedom of Information request.
During the preliminary hearing into Ms Brown's death Kate Brunner QC, for CPFT, argued it did not have “a great deal of similarity with other cases”.
But Mr Brown told the Telegraph: "From my engagement with other people that have been through similar experiences to myself, I would say there is a great deal of similarity with other cases – not just ones coming to fruition here, but across the country."
David Hemings, senior coroner for Cambridgeshire, told Ms Hart’s father earlier this year that her case was “inextricably linked/entwined” with the four other investigations.
A CPFT spokesman said the death of any patient is a "tragedy". He said but added the assistant coroner at recent pre-inquest hearings had yet to make "findings, determinations or conclusions with respect to any of the five inquests, let alone with regard to any definitive links between them."
He added: "We are proud of the work our staff do and the Care Quality Commission recently rated our services as ‘good’ during its most recent inspection."
A Government response, published last month, acknowledged there was still “further to go,” highlighting a commitment that for the next five years, the budget for mental health services will grow faster than the overall NHS budget It said the GMC had written to every medical school in April seeking views on how eating disorders are taught and will share its findings with the committee.
Nadine Dorries, the newly-appointed Mental Health minister said it is "vitally important" that those in need have timely access to the right mental health supports.
"We absolutely know that despite our very best efforts, we don't always get things right," she said, adding: "The NHS is learning from times it has previously failed patients and following avoidable tragedies, we have taken great strides in transforming the nation's mental health services."
She continued: "While progress has been made, I’m not so naive as to not realise we still have a long way to go to ensure no one struggling with an eating disorder slips through the net. I vow to do all I can to ensure we see real change towards helping people to ultimately lead healthier and happier lives."
Averil Hart was found unconscious on the floor of her university flat just ten weeks after embarking on a creative writing course.
She was rushed to hospital but was not seen by a doctor for almost five hours - a delay since branded "inexplicable". It took a further three days for the local eating disorder to attend and her condition deteriorated.
Ms Hart was transferred to Addenbrooke's Hospital on December 11. Overnight her blood sugar fell but she did not receive appropriate treatment and fell unconscious, suffering brain damage. She died three days later.
Her father, Nic Hart, has campaigned tirelessly ever since, motivated by his “intense belief” that his daughter had been failed.
Eventually, it was confirmed in an ombudsman’s report that she was let down by every NHS organisation tasked with her care.
But Mr Hart has warned that such services are still dangerously understaffed and that patients remain at risk. “It’s pretty clear to us that there are systemic failings,” he said.
“Eating disorder services are so poor. We need national change.”
Academically brilliant, with a black belt in karate, Ms Hart had shone at school, embracing life with great vigour and enthusiasm.
She fell ill with anorexia whilst studying for A ’Levels, which spiralled once she had completed her exams.
A late diagnosis meant she was very ill when she was eventually admitted to Addenbrooke’s.
Ms Hart remained in hospital for nearly ten months before leaving to begin her studies at the University of East Anglia.
But the transfer to outpatient care under Norfolk Community Eating Disorder Service (NCEDS) was fraught with problems, not least a delay of two-and-a-half months between discharge and her first appointment.
Her care co-ordinator was a junior psychologist who had never treated anyone with anorexia and failed to track her weight.
Her parents said she was “literally starving to death” while they made emergency calls pleading for urgent intervention to care for their daughter. None was forthcoming and she was found unconscious by a cleaner in her flat, losing her life one week later. Her full inquest will be heard in March.
Emma Brown was a force of nature, “frighteningly clever” with the potential to do huge good in the world.
But she was struck down with anorexia when she was just 13, ultimately using that intellect to fight every bit of help given to her, leading to her eventual death last August, at 27.
Her father, Simon Brown, a management consultant, said the family had been on a horrific journey that had seen the illness transform his talented daughter into someone hardly recognisable.
Ms Brown died at her home in Cambourne just days after discharging herself from a two-month stay in Addenbrooke’s Hospital, Cambridge.
Her inquest is one of five that has been linked by a coroner who will determine whether there are systemic failings within the NHS Trust.
“Emma’s story is horrendous - what she went through for 15 years, the suffering she endured, is almost unimaginable,” Mr Brown said.
“It’s a very, very difficult illness to treat; the only mental illness where the sufferer fears recovery more than the prospect of getting ill.
“She was at risk of death from 17 and could have died at any point.”
But rather than seek to lay blame, Mr Brown is focusing his energies on transforming the system in a bid to prevent others going through what his family has had to endure.
He believes that the system should be turned on its head, with the focus on treatment when patients are in recovery, rather than simply targeting resources on those rushed in when they are almost beyond help.
“At a very high level, it’s very clear to me that we are unable to find effective ways to treat this increasing and deadly illness, as well as the impact of anorexia,” he said.
“We have got a system that can’t deal with the reality. “It’s incredibly difficult and we have not cracked it. But until we crack it, we are not going to stop.
“Victims become highly manipulative.
“One of my observations really is that there was no process to look above and beyond the chaos - see what was happening at a big picture level and realise that the mental health assessments were never going to work with Emma.
“I want to work to get change, such that we can use our experience to help others.”
An aspiring doctor, Miss Wallace was studying medicine at Edinburgh University when she died aged 18 at Peterborough City Hospital last March.
Known to those who loved her as Maddy, she had sat her A-levels in the hospital school room and had loved embarking on her subsequent medical training.
Her family say she spoke variously of becoming a surgeon, an expedition doctor or a paediatrics specialist - potentially with a charity such as MSF (Doctors without Borders), for which they have since raised several thousand in her name.
Friends speak about the "true empathy" Miss Wallace showed for others, describing her as "funny, independent, headstrong, warm and intelligent."
Sally Pinnegar, a family friend, said: "Eating disorders slowly destruct, mentally and physically, but to be taken seriously by a doctor it seems one literally has to be stretchered in to their office, and even then it's a lottery."
Miss Jakes, a former waitress, died at Addenbrookes Hospital last August when she was 24, having battled anorexia since the age of 12.
A friend said she had been let down by a system that had failed to section her when she most desperately needed help.
"They had chances to section her, but didn't," the friend told the Telegraph.
"Although I think they should have kept her in, she would find a way around whatever was asked of her.
"If she was given a drip, she would take it out.
"It seemed they gave her too much leeway.
"Those treating would tell her friends that she had rights that had to be respected. At the same time, I heard them telling her that she was killing herself.
"After her death she was found to have hoarded bags full of medicine, including laxatives and cold drink sachets. The internet didn't help because she knew would find out what drugs to take."
Ms Bowles died at her home in Cambridge in 2017. She was 45.
Her parents, Daniel and Jenny, who live in Scotland, said that they and her son, Ussi, were "heartbroken" by her death.