Eating disorder inquest: Averil Hart's care unit in Norfolk faced 'staffing crisis'

There had been a "staffing crisis" within the eating disorder team that cared for a student with anorexia before her death, an inquest heard.

Averil Hart, 19, died in December 2012 days after collapsing at the University of East Anglia (UEA).

A consultant psychiatrist, then with Norfolk Community Eating Disorder Service (NCEDS), told an inquest it was "difficult" to recruit trained staff.

He added Miss Hart "should have" had an assessment clinic as a new patient.

Miss Hart, of Newton in Suffolk, began a creative writing course at the UEA in Norwich in September 2012, having left the eating disorder unit at Addenbrooke's Hospital in Cambridge in August after a 10-month admission.

The inquest heard there was a "very unusual" and "bespoke" set up for Miss Hart after her discharge - under the care of a psychologist until she began university and then under the care of NCEDS.

It heard that because of the arrangement Miss Hart did not go through NCEDS's assessment clinic as a new patient.

The psychologist Miss Hart had after discharge was concerned about her rapid weight loss, the inquest heard.

Dr Jaco Serfontein, who had been a consultant psychiatrist with NCEDS, said: "I would have asked for fortnightly blood tests."

The assistant coroner for Cambridgeshire and Peterborough, Sean Horstead, asked him: "Then why didn't you?"

"I assumed she had been through the assessment clinic," he responded.

He also said that in summer 2012 there was a "staffing crisis" at NCEDS and it had been "frustrating" and "difficult" to recruit trained staff.

Dr Serfontein said Miss Hart was not mentioned at a meeting discussing at-risk patients until her father Nic Hart had contacted doctors with concerns about her weight loss over the past month.

Dr Serfontein said there was now a formal "high-risk" register for patients at NCEDS, which was not the case in 2012.

When asked why he was not concerned about test results or a lack of them from the GP, Dr Serfontein said: "I assumed bloods were taken and there were no concerns about them."

The assistant coroner said that "in fact a whole category of data had not been obtained".

Dr Serfontein said: "If I had known, I would have requested urgent medical monitoring."

He later added: "My opinion now is she really should have come through the assessment clinic, which would have included psychiatric involvement in her case."

The inquest continues.

If you are affected by any of the issues in this story, you can talk in confidence to eating disorders charity Beat by calling its adult helpline on 0808 801 0677 or youth helpline on 0808 801 0711.

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