Open letter to the press about the failings of the Parliamentary Health Service Ombudsman

Mr. N Hart

Newton Leys

Joe’s Road


Nr Sudbury


CO10 0QE

Dame Julie Mellor

Millbank Tower

21-24 Millbank




31 January 2017


Re: Your investigation into the Death of Averil Hart aged 19

Dear Dame Julie Mellor,

After nearly three years of frustration and heartache, I write to inform you of the extreme difficulties and problems that I have encountered with the Ombudsman’s services and the pain that it continues to cause myself and the rest of Averil’s family.

Averil Hart died in the care of the NHS Trusts that were entrusted to look after her. During her ten weeks at the University of East Anglia, whilst in the care of Cambridge and Peterborough Foundation Trust (CPFT) and the University of East Anglia Medical Centre, Averil became critically ill. She literally starved to death in the care of the NHS whilst suffering from the treatable illness, Anorexia Nervosa.

After being found unconscious in her kitchen, Averil was taken to Norfolk & Norwich University Hospital, where it became evident they were ill-equipped and inexperienced in the treatment of a patient suffering from Anorexia. At the request of her family, Averil was moved to Addenbrookes’ N2 Ward where a further mix-up by a consultant subsequently lead to Averil’s death on the 15th of December 2012.

In August 2014, Averil’s family and I submitted an extremely comprehensive complaint and dossier regarding the death of our daughter to the PHSO. It detailed exactly what had occurred in the weeks leading up to Averil’s death. We were promised a well-resourced investigation by the Parliamentary and Health Service Ombudsman (PHSO). This investigation would be completed within 12 months, at the end of which a report would be laid before Parliament.


We have found that the service of the PHSO has failed us in virtually every aspect:

  • It has been 890 days since our submission to the PHSO and after more than 10 meetings with five different investigators, all assigned to our report and then resigning from their position, we still feel the PHSO investigation is far from complete. The PHSO seems unable to appreciate this and has only apologised for delay in its process, even though they have failed at every juncture of this process. Unable to recognise the additional pain and suffering they are causing to Averil’s family by their delays and total incompetence.
  • The PHSO has intensified our grief through its failure to find accountability for the failings of the NHS care. It is clear that there were failings by individuals in Averil’s care and these failings should be clearly identified.
  • The PHSO has failed to collect key data in the investigation and furthermore failed to recognise and report on key failings of the NHS trusts involved. Particularly with regard to the care provided to Averil by CPFT and the Norfolk Community Eating Disorder Service, where a trainee care coordinator with no experience of Anorexia Nervosa was allocated to be Averil’s sole provider of care.
  • The PHSO, in failing to investigate the NHS Trusts adequately in relation to the care received by Averil, have not been able to supply their experts with key information on which to base their findings. This has resulted in expert opinions that are fundamentally flawed.
  • The PHSO has failed to investigate a cover-up of Averil’s death by CPFT, despite admitting that they know that clinicians have been lying about events. This failure of justice causes us great distress, especially as we know that there is no arbiter beyond the PHSO. The care failings were appalling, and the cover-up adds serious injury.
  • Numerous promises have been made during meetings (recorded with transcripts) by the lead investigators that have not been met. For instance we were promised by Mick Martin (ex- Deputy Ombudsman and Managing Director) that the PHSO were going to change their findings and that they were in agreement with our initial submission. However, we have seen no evidence of these promised changes.
  • The PHSO’s findings have been shaped by advice from their clinical advisors, but we have not received satisfactory assurance that the clinical advisors are suitably qualified and impartial, given the very small and specialist world of Eating Disorder psychiatry.
  • Despite all of our input, the PHSO investigation has taken twice as long as originally promised and is still far from complete. A contributing factor to this monumental delay is that the four PHSO investigators looking at Averil’s case have ALL resigned. This seems even more absurd when you consider the fact that Averil’s family were promised adequate resourcing on a number of occasions and if more investigators were needed to compile a comprehensive and timely report, then they would be “provided.” The PHSO have even regularly failed to provide the promised weekly updates on the progress of their investigation.
  • The PHSO investigators resignations have led to Averil’s case being left in limbo. An example of this was a meeting on the 25th August 2016 held with the PHSO where we were due to meet the “new investigator”. However, upon arrival we were informed that this person had not been formally appointed and the reason for this remains unknown.
  • The work involved in the continual redrafting of the PHSO report by Averil’s family has been an extremely arduous and painful experience, however, it has been viewed as a necessity to compensate for the incompetence of the Ombudsman’s investigation. We feel there should be full and public recognition by the PHSO of the work and sacrifice by Averil’s family in the complaints process, as well as the recognition of the continual support from the Patients Association.

The appointment of Bill Kirkup to oversee the investigation into Averil’s death gave us some optimism that the PHSO would take the opportunity to address the many outstanding issues in their failing inquiry into Averil’s death. Bill Kirkup had been critical of the PHSO’s involvement in the Morecambe Bay inquiry and we mistakenly felt that there would be an opportunity for the lessons learned to be applied to Averil’s case. However, it has become obvious over recent months that there have been no service improvements at the PHSO, despite Bill’s involvement.  It continues to fail patients and families in an unacceptable way.

The numerous resignations at the Ombudsman over the past two years have left the organisation in disarray. This is evident in the lack of responses by the PHSO to our correspondence and the fact that the PHSO has not been able to stick to one single deadline in the past two years.

I find it incredible that an organisation that is funded to the tune of £40 million a year, is unable to provide a proper and worthwhile service to patients and families.

Initially, we felt that our own experience of the Ombudsman may be unusual, but actually the evidence is that the problems that we are currently encountering are common place. Since becoming more public about the PHSO’s failures we are receiving regular correspondence from those in a similar situation, including word from of a family who have waited over 140 days just to get an investigator appointed after the death of their daughter.

Apart from the direct and painful consequences to families, the NHS failings that caused Averil’s death will never be addressed unless the PHSO can make those responsible for causing harm to patients accountable and ensure permanent changes to bad and dangerous practice within NHS trusts. How many others will die whilst we wait for the PHSO to complete a fifth inquiry into Averil’s death?

Failing NHS Trusts such as Cambridge and Peterborough, despite their Duty of Candour, frequently refuse to supply key information to patients and families, citing that “an investigation is underway by the Ombudsman”. They are aware of the failings by the PHSO to investigate deaths thoroughly. In this way, NHS Trusts frequently escape criticism or detection of their negligence, and further deaths such as at Southern Healthcare, Morecombe Bay and Mid Staffs are allowed to continue.

We would ask you, despite your own resignation, to personally ensure that Averil’s case receives your immediate attention and that a fairer and more accurate report is produced with no further delay.

As this issue is of significant public interest, I am releasing a copy of this letter to the Patients Association and the media.

If you require any further information on Averil’s life and her death, please go to

Yours Sincerely,

Nic Hart

Averil’s Dad