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An NHS trust has pleaded guilty to failures over the avoidable death of a teenage girl who killed herself after absconding from 24-hour supervision under its care.
Ellame Ford-Dunn, 16, who suffered with severe mental health problems, died on 20 March 2022, minutes after leaving the Bluefin acute children’s ward in Worthing hospital, part of University hospitals Sussex NHS trust (UHSussex).
The supervising agency nurse watched Ellame leave the ward, but did not follow her because she said she had been instructed not to leave the ward if a patient absconded, Brighton magistrates court was told.
On Monday, the trust pleaded guilty to a failure to provide safe care and treatment resulting in avoidable harm. In mitigation it said the acute ward was not equipped to deal with vulnerable mental health patients, but the trust had accepted Ellame because of a “growing crisis nationally” over the shortage of mental health beds for children and adolescents.
The prosecution was brought by the hospital regulator, the Care Quality Commission. Its barrister, James Marsland, said the trust had exposed Ellame “to a risk of significant avoidable harm”.
He said its policy on missing patients “did not provide any meaningful guidance on what to do when a vulnerable patient is seen to be absconding”. He added the police created confusion among staff and noted that the nurse caring for Ellame was “under the impression she should not follow her”.
Marsland said Ellame had a complex diagnosis and was at risk of self-harm and absconding. She tried to abscond from the hospital multiple times in the weeks before her death, Marsland told the court.
In a victim impact statement, Ellame’s mother, Nancy Ford-Dunn, said: “Ellame deserved to be kept safe and get well and have a fulfilling life. Her future has been ripped from her and from us.”
Eleanor Sanderson, the counsel for UHSussex, said: “The trust accepts the core failing was the 2019 missing patient policy. It wasn’t clear about what to do when a patient absconds.”
She said the policy should have been updated to reflect the reality that a growing number of mental health patients were being cared for on acute children’s ward due to a national shortage of mental health beds.
Sanderson said: “The decision to admit Ellame to the Bluefin ward placed the trust in an invidious position. It didn’t have the resources or skill to care for her but the alternative was a refusal to admit.”
Separately, the trust is under police investigation for possible individual and corporate manslaughter over more than 90 deaths involving alleged negligence and cover-up in general surgery and neurosurgery. It is also one of 14 trusts subject to a national inquiry announced last month, into failures in maternity services.
An inquest into Ellame’s death opened last year. It was adjourned pending the outcome of the prosecution.
Ellame’s mother, who is supported by the charity Inquest, told the court: “The legal process is taking so very very long. We still await the inquest. It delays the grieving process and keeps us trapped in the details. We are surviving not living.”
She added: “There is an Ellame-shaped hole in our lives and that absence screams every day.” Ellame had been diagnosed with dyslexia, autism and attention deficit hyperactivity disorder, and found secondary school challenging, the court heard. Her mother said she loved dancing with her younger sister and swimming in the sea with her younger brother.
“Ellame was a people pleaser who always cared more about other people’s feelings than her own,” she said.
UHSussex will be sentenced on 26 November over Ellame’s death. It is expected to be issued a substantial fine.
