Service Failure of CPFT
CPFT failed Averil from the moment the decision was made to discharge her from the S3 Unit Addenbrooke's and she entered into the care of NCEDS.
Laid out below is a series of events which led to Averil's death.
Appointment of an Inexperienced "Trainee" Pyschologist
Averil's psychologist was newly qualified, new to the NHS and new to the treatment of patients suffering with Anorexia Nervosa.
Decision of Psychologist to Undertake Weight Measurements
Despite her lack of training, VP undertook to weigh Averil on a weekly basis. The consequences of this were that Averil's monitoring was reduced by trained medical professionals who knew how to accurately weight patients - it also brought a halt to all other measurements being carried out by UEA Medical Centre due to an "administration error". Due to weight falsification techniques used by anorexic patients these other measurements were vital.
Furthermore, we are unaware of the type of scales that were being used by VP and whether she was able to measure Averil's weight accurately.
Inaccurate BMI and Average Weight Recordings
VP recorded Averil's weight, rather than BMI, despite the fact that the guidelines are written in terms of BMI.
VP also failed to calculate a moving average correctly, resulting in a false sense of security about Averil's decline, resulting in an increased risk to Averil.
Delegation of Care Coordinator to Inexperienced Candidate
NCEDS, CPFT appointed VP as Averil's care coordinator even with no experience of ever performing the role and despite Averil being a high risk patient.
Delays in Commencing Treatment
Averil was referred on the 30th July, letters detail the urgency in which she needed to be 'picked up'. Averil was not seen until the 19th October, which was three weeks after she started university.
Failure of VP to Notice Weight Falsification and Physical Changes
57% of outpatients engage in weight falsification, and Averil's diary shows that she routinely falsified her weight at the NCEDS sessions. VP should have been trained to be aware of this risk and to take appropriate actions to prevent it.
Averil also notes physical symptoms that are symptomatic of significant weight loss and deterioration of health, including odema. VP lacked medical qualifications, yet concerned herself with the physical monitoring of Averil but was unable to notice these warning signs of Averil's deteriorating condition.
Failure of NCEDS to Consider Appropriateness of Treatment
Cognitive Behaviour Therapy (CBT) is knows not to be effective on patients with a BMI of under 15, yet all the times CBT was administered, Averil's recorded BMI was below this level.
Neither VP nor her supervisors considered changing the course of treatment in light of Averil's condition.
Failure of VP to Follow Procedures for Absences
VP organised leave at the end of November,but having declared Averil a high risk patient, failed to follow NCEDS procedures for arranging holiday cover. She was aware of the risk of sudden weight loss, and Averil's already reduced BMI, yet did not act accordingly. This endangered Averil and this ultimately left her without supervision in the 2 weeks that led up to her collapse.
Failure of NCEDS to Supervise their Under-qualified Team Member
Neither VP's immediate supervisor nor those higher upin the hierarchy appears to have questioned VP's records of supervisions, or have done more than check recorded weights and prompt on the development of care plans.
No checks were made regarding VP's cover during absences. They failed to ensure that VP was competent, endangering both Averil and others.
Failure to Respond Appropriately to an Emergency Call
Averil's father telephoned S3 to make them aware of Averil's condition, he was asking for an emergency review. Typically these emergency reviews should take place within 24 hours and he was assured that action would be taken.
However, no plans existed to deal with this scenario and the NCEDS team scheduled a review over a week later.