Ombudsman probes failings of its own investigation

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PHSO launches review into the failings of its investigation into the death of Averil Hart
Review will look to identify failings in its culture, methodology and how well the investigation was carried out
Father believes lessons from the investigation could have prevented four further deaths

The Parliamentary Health Service Ombudsman has launched a review of failings in relation to an investigation into the death of a young woman with anorexia, HSJ has learned.

The PHSO has launched a review of how it handled a three-year long investigation, under its previous leadership, into the systemic failings in Cambridgeshire and Norfolk which contributed to the death of Averil Hart, who died in 2012.

Nic Hart, Averil’s father, has raised concerns that inadequate investigations into her death by the PHSO had prevented lessons being learned earlier. He believes these lessons could have prevented four further deaths, which coroners say may have happened due to similar failings in the region.

Averil, who was diagnosed with Anorexia Nervosa, died aged 19 after several NHS organisations in Cambridgeshire and Norfolk failed to address deteriorations in her condition.

In 2017 the PHSO published its “ignoring the alarms” report which said Averil’s death would have been avoidable had all the organisations not failed in her care.

This came three years after it first launched its investigation in 2014, under former ombudsman Dame Julie Mellor.

The body has now agreed to review complaints from Mr Hart, around the length of the investigation, a lack of continuity and consistent lead officers; and investigators allegedly prioritising clinicians’ evidence over the family’s.

The PHSO declined to give full details of its review, but HSJ understands it will examine the PHSO’s methodology, culture and performance in relation to the investigation, and how it would be handled if a similar case happened today.

When the investigation was launched, Mr Hart told HSJ he was promised one investigator and that it would take six months. However, the investigation took three years with around five different investigators, and multiple draft reports.

He added: “When trusts and the ombudsman fail in investigations, they allow poor practice to continue, which in my opinion is what happened with Cambridgeshire and Peterborough Foundation Trust. Efficient investigations which are truly independent, can find out what’s happened and prevent future deaths.”

In 2015, a report from the Patients’ Association, accused the watchdog of taking NHS organisations’ side over patients.

A spokeswoman for the Parliamentary and Health Service Ombudsman said: “We have always been clear that there were lessons for us to learn from the process we followed in this case and are reviewing this to make sure they have been addressed through the improvements we have since made to our service. We will publish our review and share it with Mr Hart and Public Administration and Constitutional Affairs Committee once concluded.”

Dame Julie resigned in 2016 after accepting she made mistakes relating to correspondence about the involvement of her former deputy in a sexual harassment cover-up at an NHS trust. Her successor is Rob Behrens.

Story updated at 14:57 after PHSO confirmed the number of investigators was five and not 10.

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