Eating disorder inquest: 'Systemic failures' in Averil Hart's hospital care

An anorexic woman's survival chances were reduced because she was not given a feeding tube on admission to hospital, an inquest heard.

Averil Hart, 19, was admitted to the Norfolk and Norwich University Hospital (NNUH) on 7 December 2012.

An expert report's author, Dr James Stewart, said because of her severity she should have been fed through a nasogastric (NG) tube upon admission.

Miss Hart, 19, died at Addenbrooke's Hospital on 15 December 2012.

Dr Stewart said "systemic failures at NNUH and Cambridge University Hospitals [which runs Addenbrooke's] contributed to her death".

Creative writing student Miss Hart, of Newton in Suffolk, was admitted to hospital after being found collapsed in her University of East Anglia room.

Dr Stewart, who has worked as a clinical lead for eating disorders, said due to the seriousness of her illness, not starting NG feeding on admission reduced her chances of survival.

Asked by assistant coroner for Cambridgeshire and Peterborough Sean Horstead about her prognosis on admission to NNUH, Dr Stewart said she had a 50% chance of survival to discharge, which may have risen to to 80% had NG feeding been started upon arrival.

He said other failings in her care were a delay in dietic review and no specialist advice from psychiatrists or dieticians being sought over her weekend admission.

The inquest heard throughout her time at NNUH no food log was kept and sparse notes were made about food intake based only on conversations with Miss Hart.

Dr Stewart said the lack of a food chart was a "serious omission".

Overall there were "missed opportunities" for intervention in Miss Hart's care, he said.

Following a transfer to Addenbrooke's there was a further "critical delay" as Miss Hart was not seen by a consultant for nearly three hours due to a miscommunication, said Dr Stewart.

"That struck me as a red flag missed opportunity," he said.

He said her chance of survival to discharge was just 20% by the time she arrived at Addenbrooke's but if she had been seen within an hour that may have increased.

The inquest in Peterborough 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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