1Introduction: The PHSO report and our inquiry
Ignoring the Alarms
1.One estimate of the numbers of people with eating disorders in the UK is between 600,000 and 725,000.1 An alternative estimate suggests the figure is 1.25 million.2 Regardless of precise figures, it has been suggested that eating disorders may be one of the most common mental health problems.3 Accordingly the provision of effective treatment and services for people who have an eating disorder is a serious matter for society.
2.In December 2017, the Parliamentary and Health Service Ombudsman presented to Parliament a report entitled Ignoring the Alarms: How NHS eating disorder services are failing patients (“the report”).4 The report 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’s conclusions were as serious as the title suggested. The investigation into Averil’s death found that:
- several NHS organisations missed opportunities to prevent Averil’s deterioration which led to her hospital admission;
- there was inadequate coordination planning of Averil’s care;
- there were failures in two acute trusts when she was seriously ill; and
- there were failures in the handling of the family’s complaints about the circumstances of her death.
3.The report found that these failures were not unique to Averil’s case and concluded that “there were serious issues that required national attention.”5
4.The PHSO’s report listed five wider recommendations which broadly highlighted five key areas for improvement:
- 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 Ombudsman and our inquiry
5.The Parliamentary and Health Service Ombudsman (PHSO, or ‘the Ombudsman’) is independent of the Government, the NHS and Parliament. It reports to Parliament and is accountable to the Public Administration and Constitutional Affairs Committee (PACAC), which scrutinises its reports, and the overall performance of the PHSO and for its use of resources. PACAC usually holds an annual evidence session based on the PHSO annual report and accounts. The Ombudsman can lay reports before Parliament, often to highlight cases that he feels raise issues of wider concern. Ignoring the Alarms was one such report.
6.We launched this inquiry to highlight the report’s findings and investigate what progress had been made in implementing the PHSO’s recommendations. To respect the House’s sub-judice resolution, we have only considered the report’s wider recommendations, as the inquest in the case of Averil Hart has not yet been concluded.
7.For this inquiry we received 17 pieces of written evidence. Due to the sensitivities involved and with the agreement of the witness, we have not published one of the submissions we received. We also held an evidence session, hearing from:
- The charity, Beat Eating Disorders (“Beat”), and the Faculty of Eating Disorders of the Royal College of Psychiatrists;
- Health Education England and the General Medical Council; and
- NHS Improvement and NHS England, and The Minister for Mental Health, Jackie Doyle-Price MP.
8.We also held an informal seminar on 6 June with people who had lived experience of having, or being carers for people who have, a variety of eating disorders to better understand their experiences. We are grateful to everyone who supported our inquiry.
9.If you are affected by any of the issues raised in this report or are looking for support with an eating disorder, one provider of such support is Beat: https://www.beateatingdisorders.org.uk/support-services.
1 Department of Health and Social Care, Health Education England and the National Institute for Care Excellence, IDF0017
4 Ignoring the Alarms: How NHS eating disorder service are failing patients, Parliamentary and Health Service Ombudsman, December 2017, HC 634. The report was presented to Parliament pursuant to Section 14(4) of the Health Service Commissioners Act 1993.
5 Ignoring the Alarms: How NHS eating disorder service are failing patients, Parliamentary and Health Service Ombudsman, December 2017, HC634, p 2
Published: 18 June 2019