Ignoring the Alarms follow-up: Too many avoidable deaths from eating disorders Contents


In December 2017, the Parliamentary and Health Service Ombudsman (PHSO) presented to Parliament a report entitled Ignoring the Alarms: How NHS eating disorder services are failing patients, which was published following the PHSO’s investigations into the case of the death of Averil Hart (aged 19) and two others (Miss B and Miss E).

The report made five wider recommendations relating to: the training of doctors and other medical professionals; the quality and availability of adult services, and the transition from child to adult services; improving coordination when more than one service is involved; using training to address gaps in provision of eating disorder specialists; and improving investigation and learning, in particular from serious incident investigations.

The purpose of our inquiry was to examine what progress had been made on each of the PHSO’s recommendations. While we welcome the steps a number of organisations have taken in response to the PHSO’s report, we have concluded that further action needs to be taken under each of the report’s recommendations.

We found there is a serious lack of training for doctors about eating disorders and recommend that the General Medical Council use its influence to ensure medical schools improve outcomes in relation to eating disorders.

We also find the lack of precise information about the prevalence of eating disorders to be shocking, given claims up to 1.25 million may have eating disorders. As a matter of urgency NHS England should commission a national population-based study to properly assess how many people have an eating disorder.

We believe the Minister and the Department for Health and Social Care can play a leadership role in ensuring progress against the PHSO’s recommendations. We have therefore asked the Government, in its response to our report, to produce a timeline against each of the PHSO’s recommendations; what steps have been taken, what further steps will be taken under each recommendation and what funding will be allocated for those actions, with deadlines and responsible owners listed.

Due to the ongoing inquest into Averil Hart’s death we have confined our inquiry to the wider recommendations, out of observance of the House’s sub judice rule. Once proceedings relating to that have finished, we will consider the PHSO’s investigation in greater detail. As part of that work, we will return to examine progress against the five wider recommendations.

Published: 18 June 2019