Prevention of Future Deaths report – Averil Hart

Summary

Averil Hart died from anorexia nervosa at Addenbrookes Hospital, Cambridgeshire, 6 days short of her 20th birthday. In this report, Sean Horstead, Assistant Coroner, concluded that Averil's death was avoidable and that it was contributed to by neglect.

Content

The following concerns are highlighted in the report:

• Inadequate training of doctors and other medical professionals re eating disorders.
• Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk anorexia nervosa patients by primary or secondary care providers.
• Lack of robust and reliable data regarding the prevalence of eating disorders.
• The impact of the COVID 19 pandemic.