'She was unique but her case is not': Averil Hart's father calls for coroner's recommendations at inquest to be rolled out across UK to prevent further eating disorder deaths

A budding writer. A brilliant friend. A beautiful soul.

Someone who would light up the room around her, and have everyone dancing to her tune.

A woman who would have gone on to wow the world with her talents and knowledge. A fighter.

That's how the family of Suffolk teenager Averil Hart describe their daughter and sister, who died after a battle with anorexia nervosa in 2012.

A five-week inquest which came to a close on Friday saw the assistant coroner for Cambridgeshire, Sean Horstead, record a narrative conclusion in which he said that the 19 year old's death 'could have been avoided' had it not been for systemic failures and neglect in her care.

Nic Hart, Averil's father, has been waiting eight years for the truth to come out about the health trusts which failed his daughter, who was from Newton near Sudbury.

"You know what the conclusion should be going into these things but it's still hard to hear it when it comes," he said.

"It is not a relief to hear that your daughter's death could have been avoided, especially when I speak to other families of girls who died after Averil who were failed in the same way.

"You just wonder: why don't they listen?"

Averil, a bright, sociable girl who was the youngest of three sisters, had started studying English literature with creative writing at the University of East Anglia just 10 weeks before she died.

For 10 months prior to going to university, she stayed in the S3 ward - for adult eating disorders - at Addenbrooke's Hospital, Cambridge, determined to beat the illness that had taken over her body and her life.

"One of the things which was highlighted at the inquest was that there as a gap in her care between being discharged from Addenbrooke's and going to university," said Nic.

"She began to lose weight as soon as she was discharged and because of the lack of a proper hand over between Cambridgeshire and Peterborough NHS Foundation Trust and the Norfolk Community Eating Disorder Service (NCEDS), she wasn't evaluated and they didn't do a proper health check.

"If they had, they would have seen she was already losing weight and that her risk level had risen."

During her time at university, Averil struggled to cope with her eating disorder - a struggle she recorded her in diaries, one entry in which read 'Dear God, please help me'.

This wasn't helped by the fact that NCEDS was going through a staffing crisis, which meant that the teenager was allocated a trainee psychologist to care for her.

"She needed help and wasn't getting it," said Nic. "She was as aware as we all were that the system was failing her, that they weren't doing anything about it."

Averil's condition rapidly worsened to the point that it was noticed and reported by not only her family, but also her tutor, the cleaner at her university halls, and even her aunt who lived 12,000 miles away in New Zealand.

And just weeks before her death on December 15, Nic raised the alarm again after a traumatic visit to the teenager's student halls saw him burst into tears.

"I saw her in November and it was obvious that she'd lost so much weight. Her BMI was at about 11 and it was clear she wasn't getting the care she needed," he said.

"She was slurring her words and she couldn't stand up. I was extremely upset, it came as such a shock."

In her final days, Averil was found unconscious in her university flat and was rushed to accident and emergency at Norfolk and Norwich University Hospital.

"They failed for four days to give her any food at all of any substance," said Nic.

"She got so much worse and her condition deteriorated so she was transferred to Addenbrooke's, where she wasn't seen for four hours and wasn't registered for 10 hours - during which time she nearly died and went into a hypoglycaemic coma."

It was in her hospital bed in Addenbrooke's, with her family by her side, that Averil suffered a heart attack and died.

Since that day, the Hart family have campaigned to ensure lessons are learned from the death of their 'warrior princess', who they believe 'would be alive today' had it not been for the gaps in her care.

"Every service which was supposed to look after her failed her in some way," said Nic.

"When someone dies and questions are raised about their care, it should not be the NHS trusts in question which investigate it. The clinicians who treated her should not be the ones to come up with what went wrong. That is no way to improve the system."

And Nic believes the system hasn't improved, with the inquests of five other women - Maria Jakes, Emma Brown, Amanda Bowles, Madeleine Wallace and Lydia Stafford - who died from eating disorders having run alongside Averil's as part of the investigation into the services.

"Most families would want to know what caused the death of their child and want to know that things are going to be put right for other parents that go through the same thing," he said.

"I want people to realise that this is not a one off. This is not just about Averil. Of course all cases are not the same but they are similar in the way they were handled.

"Averil was unique but sadly her case was not. It's important that it isn't seen as obscure or uncommon."

Nic is now calling for the coroner's recommendations to be rolled out nationally to ensure people suffering from eating disorders are able to access the care they need.

"There is lots still to be done. We need the recommendations from the coroner to be taken forward at national level and properly funded.

"We need constant monitoring for patients in the community and we need to prevent further deaths.

"It's devastating to have lost Averil. While, in terms of a final process, the inquest brings some closure, in terms of grief, that's a different thing altogether. That will take a long time."

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