The NHS is trying to make the deaths of five anorexic women seem “inevitable” despite stinging criticism from the coroner, the father of one victim has claimed ahead of his daughter’s inquest.
Inquests into the deaths of all five women were linked following allegations that they received insufficient care, amid a growing crisis in the treatment of eating disorders.
Averil Hart, 19, 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).
Sean Horstead, the assistant coroner for Cambridge, will on Monday begin hearing the fifth and final inquest, concerning Miss Hart’s death, which was described in an ombudsman's report as an "avoidable tragedy".
The coroner has indicated that he will be writing a prevention of future deaths report after the inquest heard about a litany of failings, which he ruled in one case had directly contributed to a fatality.
He is expected to call for urgent changes to eating disorder services nationwide, having warned of widespread “structural failings”.
He has noted that efforts to improve monitoring have been "frustrated by insufficient uptake by GP practices" across the UK.
Nic Hart, Ms Hart’s father, who has attended all four inquests to date, said he had not been prepared for how “defensive” the trust would be or what a “rigorous” defence it would put up, at significant cost, in order to seemingly absolve itself of blame.
He told The Telegraph: “Rather than hold up their hands and say 'we made massive mistakes', their tendency has been to offer up other explanations and that's really disappointing.
“They are trying to make it look as if these deaths were just inevitable.”
Miss Hart was found unconscious on the floor of her university flat in December 2012, 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 specialist to attend and her condition deteriorated. She was transferred to Addenbrooke's Hospital in Cambridge on December 11 but died three days later.
Mr Hart has campaigned tirelessly ever since, motivated by his “intense belief” that his daughter had been failed by NHS teams at every level.
He said his daughter was "literally starving to death" when he and his wife made emergency calls pleading for urgent medical intervention.
She had been discharged from hospital into the care of the Norfolk community eating disorders team and a medical team at the University of East Anglia.
But her family say she was denied proper checks, despite a rapid decline in her weight, and that the unit was understaffed and under-resourced.
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 said insufficient progress had been made.
Miss Hart’s family have been forced to endure an eight-year wait for her inquest, whilst they said that they have discovered more and more failings at every turn.
Mr Hart said: “What I find very difficult to handle is that it took three-and-a-half years to get the ombudsman's report, at the end of which the trust was told their services had failed and there was maladministration in their complaint and yet here we are three years later, in a court for an inquest where they are trying to persuade the coroner that actually they did nothing wrong.”
He said the CPFT had spent well over £100,000 defending itself at the inquests, money that he believes should be ploughed into cash-strapped services.
“To me, the inquest should take a week, sat around a table to discuss, rather than argue the toss on everything,” he added.
“They should work out what went wrong, admit it and then spend the money on patient care. It’s too easy to say there were mitigating circumstances and then just bat it away.”
The family is hoping that the coroner will manage to get “open and honest” answers from the trust to a number of outstanding questions.
“I also hope the trust will start to appreciate that had they actually taken heed of what we were saying in 2013, other deaths may have been prevented,” he added.
“If they listen now, lives can still be saved.”
Mr Hart was contacted just two weeks ago by the father of another young woman who had just died from anorexia and who was under the care of the same NHS trust, another family desperate to ensure that the same thing does not happen to anyone else.
A spokesman for Cambridgeshire and Peterborough NHS Foundation Trust said: “It would not be appropriate to comment on the detail ahead of the upcoming inquest but we express our condolences to Averil’s family.
“The Trust will continue to act on all learnings and is committed to the development of eating disorder services, and we are working with local services on plans to improve the community treatment for adults.”
The four other cases linked by the coroner
Maria Jakes, 24.
Died August 20, 2018 Inquest: December 2019
Miss Jakes, a waitress from Peterborough, died following a decade-long battle with anorexia.
Mr Horstead ruled that “insufficiently consistent and robust monitoring” of her condition, particularly following her discharge from hospital in January 2018 until her readmission seven months later, may have contributed to her death.
He said insufficient record-keeping and a lack of eating disorder specialists had contributed to the lack of monitoring.
The inquest found that the failure of her GP and the staff of Peterborough City Hospital to notify psychiatry or eating disorder specialists of her readmission shortly before she died was also a “missed opportunity”.
Emma Brown, 27
Died August 22, 2018 Inquest: January 2020
Miss Brown, from Cambourne, near Cambridge and had dreamed of being an Olympic runner, was found dead in her flat by her mother after struggling with anorexia for more than a decade.
Her father, Simon Brown, described her “descent into hell” after being diagnosed with the illness at 13, which she developed after being bullied at school.
Mr Horstead said the “highly intelligent and ambitious” woman had required frequent readmission to Addenbrookes Hospital, including 17 over the course of 2017- 2018 alone.
He expressed concern at the “paucity of the investigation” conducted by Cambridgeshire and Peterborough clinical commissioning group instead of a serious incident report and noted that there were no interviews with Miss Brown’s parents or “key clinical figures”.
After the hearing, Mr Brown said: "Anorexia nervosa is not a good way to die.
"None of you, none of the people who have been following the inquest can understand how much suffering Emma endured and it is heart-breaking to imagine that others might suffer the same.”
He added: "At the heart of this is the difficulty we have in investing resources in prevention and the recovery strategy of the illness.”
Madeleine Wallace, 18
Died January 9, 2018 Inquest: February 2020
Miss Wallace was studying medicine at Edinburgh University when she decided to put her studies on hold to return home to Peterborough to focus on her recovery from anorexia.
She was placed on a waiting list for psychological treatment but died the following month after contracting sepsis.
The inquest heard that Miss Wallace, 18, attended both A&E and her GP surgery in the days before her death but a bacterial infection went undiagnosed.
An independent review of her case highlighted a lack of knowledge about complications, such as infections by GPs and medical staff.
It made 14 recommendations for changes to prevent gaps in care at a national and regional level, the inquest heard.
Mr Horstead said GPs' knowledge of eating disorders was "woeful and inadequate" but that "different clinical decisions" would not have prevented her death.
Miss Wallace's parents, Christine Reid and Stuart Wallace, called for urgent changes to be implemented to address "NHS staff's limited experience and understanding of anorexia, and poor safety-net systems".
In a statement, they added: "There have already been too many such deaths in this region, and elsewhere."
Amanda Bowles, 45
Found dead Sept 7, 2017 Inquest: Sept 2020
Ms Bowles, a mother-of-one, was failed by her doctors before she died at her home in Cambridge, her inquest heard.
Mr Horstead described aspects of Ms Bowles’s care as “disappointing” and “surprising”, noting a "conspicuous lack of safeguarding measures."
The inquest heard she was left “entirely unmonitored” for several months before her death Mr Horstead ruled that a decision not to arrange an urgent mental health assessment in order to have Ms Bowles sectioned had contributed to her death.
He said the problems medics faced in monitoring Ms Bowles were not the fault or responsibility of either the Trust or the GP surgery, noting that the “unsavoury reality” was that it was a problem that persisted on a national scale.