Ms Campbell detailed her daughter’s medical care from when she was first admitted to the eating disorder unit at Addenbrooke’s hospital, Cambridge, in September 2011, three years after she was diagnosed with anorexia, to her death in December 2012.

She said the teenager was “very frightened and scared” and found being on the ward “terrifying.”

She was discharged the following August, despite being “below her target weight” and feeling “anxious” about going home, Ms Campbell said. But the family was told her weight had plateaued in hospital and that “this was where the hard work really begins”.

“The staff knew that Averil was at a high risk of relapse and that her discharge would be an emotional time for her,” she added. 

The family decided that Addenbrookes  should continue to facilitate Miss Hart’s care until she embarked on a creative writing course at the University of East Anglia, where it would be picked up by the Norfolk Community Eating Disorders Team (NCEDS).

However, many of the consultations were done by telephone, which “clearly did not allow a proper assessment of Averil’s weight and wellbeing,” Ms Campbell said.

“I am not aware that a doctor checked her heart or any other critical medical parameters at any time following her discharge,” she added.

Miss Hart was not allocated her NCEDS care co-ordinator, Vikki Powell, in Norwich for three weeks, and even then, her physical and mental health was not properly monitored, her mother said.

Diary entries, not available to family or clinicians at the time, reveal that she knew her condition was deteriorating and that the anorexia was “getting away with a lot”. In November, she wrote: “I can’t believe I’m still going.”

“If Averil could recognise this, how come Vikki Powell did not hear alarm bells?” Ms Campbell asked.

When Ms Powell went on holiday for two weeks, Miss Hart was left unsupervised, with no therapy sessions, her mother said.

She rapidly deteriorated and was rushed to hospital on December 7, 2012, when she collapsed.

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