Written evidence from Beat (PHO 21)

Public Administration and Constitutional Affairs Committee

Parliamentary and Health Service Ombudsman Scrutiny 2020-21 inquiry

Executive summary

• In December 2017 the Parliamentary and Health Service Ombudsman (PHSO) presented its report titled ‘Ignoring the alarms: How NHS eating disorder services are failing patients’[1] to parliament.

• This report presented the findings of its investigation into the death of Averil Hart and outlined some similar failings in the care of two other individuals. This report made recommendations aimed at addressing systemic failings to prevent further avoidable tragedies.
   
• The PHSO has acknowledged that it took far too long to complete this investigation[2]. This delayed the publication of its vitally important recommendations.
   
• This PHSO report1 has had an important impact on the organisations that were the subject of its recommendations, and some progress has been made. However, as shown by the committee’s 2019 ‘Follow-up’ inquiry[3] and the recent ‘Prevention of future deaths’ report[4], the relevant organisations have still not adequately responded to the concerns and recommendations raised by the PHSO report, and there is a need for much greater urgency. As the committee stated in its 2019 follow-up inquiry: “lives will continue to be lost under the status quo” (Para. 83).

• Beat recommends that as soon as possible the committee conducts a further follow-up inquiry to examine implementation of the recommendations made by the PHSO in its ‘Ignoring the Alarms’ report1.

1.    Introduction

Beat is the UK's eating disorder charity. We exist to end the pain and suffering of eating disorders, and we are here to help anyone affected by these serious mental illnesses[5]. We provide information and support through Helplines, which people can call, text or email. We also run online support groups and HelpFinder, an online directory of support services.

We campaign for change in policy and practice, as well as providing expert training, resources and consultancy to health and education professionals, and we support and encourage research into eating disorders.

We are submitting evidence to this inquiry as the terms of reference refers to examining “the Ombudsman’s performance in the role over the past five years”. We would like the committee to consider the conduct and impact of the Parliamentary and Health Service Ombudsman’s (PHSO) investigation into the death of Averil Hart, which culminated in the publication of a report titled ‘Ignoring the alarms: How NHS eating disorder services are failing patients’1. This was presented to Parliament in December 2017.

2.    The PHSO’s investigation into the death of Averil Hart

2.1.            Averil Hart died on 15 December 2021, aged only 19. She had been suffering from anorexia nervosa.

2.2.            As the PHSO noted in his ‘Ignoring the alarms’ report1, a thorough independent investigation into Averil’s death should have been commissioned jointly by all the NHS organisations that had been involved, to examine failures in her care across all these organisations and failures of communication between them.

2.3.            Instead, the PHSO found that the NHS organisations involved conducted their own piecemeal and poor quality investigations1. After examining the responses of these organisations, the Ombudsman found that collectively this represented:
 

“…a consistent picture of unhelpfulness, lack of transparency, individual defensiveness and organisational self-protection that is of great concern. It is hardly surprising that this leads to a lack of trust from complainants, in this case Mr Hart. Equally unacceptable are the missed opportunities to learn and to improve services inherent in the incomplete and defensive investigations of safety incidents such as this.” (p.11).

2.4.            Therefore, it was vitally important that the case of Averil Hart’s death and the seriously inadequate response that followed from the NHS organisations that had been involved, was thoroughly and independently investigated by the PHSO within a reasonable timescale - both for her family and for the safety and welfare of future patients and their families.
 

2.5.            The PHSO first received a complaint from Mr Hart in August 2014 (we note that the current Ombudsman did not start in post until April 2017). Unfortunately, the pain and frustration that the Hart family had already experienced was extended by delays in the completion of the PHSO’s investigation2. It took the PHSO three years and four months to complete this investigation and publish its findings2. The Ombudsman acknowledged this in its ‘Ignoring the alarms’ report1 stating:

“We took too long to complete the investigation and I sincerely apologise to Mr Hart and his family for the delay.” (p.2)

”Averil Hart’s case has important lessons for us too. We are currently in the process of developing our new three year strategy and the lessons from our handling of this case have informed some of my thinking in this area. In particular, I am determined to resolve complaints more quickly in the future so that important service improvements can happen without delay.” (p.3)
 

2.6.            An internal review by the PHSO published in January 2020 found that this investigation should have been completed in half the time2. It concluded that delays had been partly due to insufficient resource having been allocated to the investigation. It also found that five different caseworkers and seven managers had been involved across the three years and four months that it took to complete the investigation, and that “Information was sometimes lost because handovers were not always handled effectively.” (para. 7.10, page 10).
 

2.7.            In the conclusion of this internal review the PHSO asserted2 that:

“…since Mr Hart’s complaint was concluded, there have been significant improvements in PHSO’s approach to handling complaints drawing on lessons learnt from this case. In each area where failings have been identified, PHSO has either made improvements or is in the process of making improvements to help make sure it will not make the same mistakes again. The review did not identify any gaps where further changes to PHSO’s approach to handling complaints should be considered.” (para. 10.3, page 19).

3.     ‘Ignoring the Alarms: How NHS eating disorder services are failing patients’

3.1              In December 2017 the PHSO published ‘Ignoring the alarms: How NHS eating disorder services are failing patients’1. This report highlighted systemic failings requiring urgent and coordinated action. It made five ‘wider recommendations’ to prevent further avoidable tragedies.

3.2              In our view the publication of this report has had a significant impact on other organisations. It appeared to lead NHS England to afford greater priority to improving the capacity and quality of adult eating disorder services and led to the establishment of a ‘PHSO delivery group’ that brings together representatives from key organisations in an effort to support implementation of the PHSO report’s recommendations.

3.3              However, in 2019 the Public Administration and Constitutional Affairs Committee (PACAC) conducted an inquiry to follow-up implementation of the recommendations made by the PHSO. In its ‘Ignoring the Alarms follow-up: Too many avoidable deaths from eating disorders’ report3 the committee found that:

“A number of steps have been set out in the evidence we have received but we do not think there is enough urgency. Such urgency must reflect the fact that lives will continue to be lost under the status quo. There must accordingly be a clear picture of what actions will be delivered under each recommendation, what funding will be assigned to delivering those actions and by what timeframe those actions will be complete.” (para. 83).

3.4              The Government’s response[6] to the committee’s inquiry report included some important commitments – notably the continued operation of the PHSO Delivery group - however in our view it did not provide the full clarity that the committee had sought around what specific actions would be taken, what funding would be allocated and most notably the timescales for when these actions would be completed. Key examples of shortcomings in the Governments’ response to the committee are cited below, against relevant recommendations from the PHSO report:

3.4.1        Recommendation 1 - The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders: “Timeline: the GMC does not have the powers to conduct a review in the way the PHSO recommends. In the place of such a review, the GMC will continue to progress this work with the AoMRC and others to monitor changes on an ongoing basis, through the next steps projects listed above and its role on the PHSO Delivery Group.”
 

3.4.2        Recommendation 2 - The Department of Health and NHS England should review the existing quality and availability of adult eating disorder services to achieve parity with child and adolescent services: “Timeline: the review element of this recommendation is implemented – delivery partners will work on an ongoing basis to achieve parity with child and adolescent services taking forward the next steps actions above. The learning from the four-week waiting times for adult and older adult community mental health teams pilot sites will inform NHS England's understanding of a realistic timeline for development of adults eating disorder services to achieve parity with child and adolescent services.”
 

3.5              In March 2021 the Assistant Coroner for Cambridgeshire and Peterborough submitted a ‘Prevention of Future Deaths’ report to the Department of Health and Social care and others following his inquests into the death of Averil Hart and four other women who had all died as a result of anorexia nervosa in 2017 and 20184. The coroner found several common themes of concern across these five inquests that give rise to “a risk of avoidable future deaths” (p.4). He concluded that the concerns raised by the PHSO and the subsequent PACAC inquiry have still not been adequately addressed.

3.6              The Coroner also found4 that the matters of concern he identified “have been – and will continue to be – significantly exacerbated by the on-going pandemic.” (p.5).

3.7              In paragraph 84 of the committee’s ‘Ignoring the Alarms follow-up: Too many avoidable deaths from eating disorders’ report3 it committed to – once court proceedings had finished - “consider the PHSO’s investigation of Averil Hart’s case in greater depth. At that time, we will return to the PHSO’s wider recommendations to assess what progress has been made.”

3.8              Beat recommends that as soon as possible the committee conducts a further follow-up inquiry to examine implementation of the recommendations made by the PHSO in its ‘Ignoring the Alarms’ report1. The urgent need for such an inquiry was demonstrated by the recent ‘Prevention of Future Deaths’ report4, and its finding that responsible organisations were failing to adequately implement the recommendations of both the PHSO and the 2019 PACAC inquiry reports.

October 2021

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