Trust did not give ‘safe care’ for girl who died on hospital grounds, court told

An NHS trust failed to provide “safe care and treatment” for a teenage girl who died on hospital grounds after running from her ward, a court heard.

Ellame Ford-Dunn, 16, died after absconding and ligaturing in the grounds of Worthing Hospital whilst she was a mental health inpatient on March 20 2022.

She ran into the grounds of the hospital and was not immediately followed by a nurse due to “confusion” and a lack of appropriate procedure in place.

On Monday, University Hospitals Sussex NHS Trust (UHST) pleaded guilty to failing to provide safe care and treatment to Ellame which exposed her to a significant risk of “avoidable harm” at Brighton Magistrates’ Court.

Prosecuting for the Care Quality Commission (CQC), James Marsland said: “The trust failed to provide safe care and treatment to Ellame by not doing everything that was reasonably practicable…

“Namely that there was no adequate guidance to staff to follow a patient seen to abscond from the ward.”

Ellame had been under 24-hour one-to-one supervision by a registered mental health nurse on an acute ward at Worthing Hospital when she absconded.

She was on that ward because there was “no alternative” and no adequate bed for her risk level was available, the court heard.

“The prosecution accepts that in that particular regard the defendant trust was in a difficult position; there was no immediately available alternative at the time of admitting Ellame to Bluefin Ward,” said Mr Marsland.

He added: “No tier four was readily available and the high demand for such beds is a national issue.”

Ellame had suffered with severe mental health difficulties for some time prior to her stay at Worthing Hospital, the court heard.

The charge arose from the lack of clarity in the UHST guidelines for staff about vulnerable patients absconding.

When Ellame ran, the nurse she was with did not immediately follow her, instead alerting other staff because she had been told on handover not to follow.

The CQC said that their confusion was “a symptom of the failure to have a policy directive that such vulnerable patients ought to be followed immediately”, which has since been amended.

Ellame was found by police later that evening close to the edge of hospital grounds, and died despite CPR at the scene.

Ellame would not usually have been on the UHST ward but Sussex Partnership Foundation Trust (SPFT), who were assessing her condition, did not have capacity to provide her with an adequate bed.

“They didn’t have the resources or the skills to properly support Ellame but the alternative was refusing her,” said Eleanor Sanderson, defending UHST.

Her mother, Nancy Ford-Dunn described Ellame as a “loving and supportive big sister” who was very creative and loved art and dancing.

In her victim impact statement, she said: “She was loved so very deeply, we miss her more than words can express,

“We are asked to speak about the impact of Ellame, the impacts are all encompassing and endless,

“Our family will never be whole again, wherever we go and wherever we go there is an Ellame-shaped hole in the world.”

Chief nurse at UHST, Maggie Davies said: “The loss of Ellame was a tragedy, for her and those who loved her.

“Colleagues involved in her care are devastated by her death, and the impact it continues to have on her family and friends.

“Everyone accepts that people with acute mental illness should not be in general hospital wards or A&E departments, but we had a responsibility to protect her while she was in our care, and we offer our heartfelt apologies for not being able to do that.

“Ever since Ellame’s death we have agreed that our ‘missing person’ policy, and training around it, was not clear enough.

“We highlighted that, made improvements, and today we accepted the single charge relating to that policy.

“We are committed to working with our partners to ensure there are better ways to care for people who are at a point of such vulnerability and distress.”

The NHS Trust is likely to face a substantial fine and will be sentenced on November 26.