This turned out to be a junior psychologist who had never treated anyone with anorexia before.
Despite instructions that a GP should assess her weekly, she saw doctors as little as three times before her death on December 15.
At the final appointment a locum told her she did not need to come back for a month.
Her family later raised the alarm, and on the morning of December 7 she was found collapsed and rushed to the Norwich Acute Trust but was not seen by a doctor for almost five hours, a delay the Ombudsman called “inexplicable”.
He said that despite knowing the risks of relapsing, the doctors who discharged her in the summer had failed to put together a sufficiently robust framework to monitor Ms Hart.
The Ombudsman, Rob Behrens, said adult services needed to mirror the arrangements put in place when child anorexics leave inpatient care.
He also apologised for taking so long to publish the report, which became mired in difficulty after the five previous investigators resigned.
“Averil’s death matters to all of us because the tragedy of her death is synonymous with the ongoing national failings within the NHS and also within the investigation process when things go wrong,” said Mr Hart.
“Not only was the care that Averil received negligent, but the investigation of her death took far too long and this has resulted in further unnecessary deaths.”
Mr Behrens said: “Averil’s tragic death would have been avoided if the NHS had cared for her appropriately.
“Sadly, these failures, and her family’s subsequent fight to get answers, are not unique.
“The families who brought their complaints to us have helped uncover serious issues that require urgent national attention – I hope that our recommendations will mean that no other family will go through the same ordeal.”
Dr Dasha Nicholls, chair of the Royal College of Psychiatrists’ eating disorders faculty, said: “This report highlights the fatal consequences of a lack of medical and psychiatric oversight when patients with anorexia nervosa leave the safety of a specialist inpatient unit.
“When a patient leaves hospital, they may still be very ill and need specialist care from a dedicated team.”