NHS trust pleads guilty after teenage girl absconded from 24-hour care and killed herself | NHS

An NHS trust has pleaded guilty to failings over the avoidable death of a teenager who took her own life after running away from 24-hour supervision in its care.

Ellame Ford-Dunn, 16, who suffered from serious mental health problems, died on March 20, 2022, minutes after leaving the Bluefin children’s acute ward at Worthing Hospital, part of the University Hospitals of Sussex (UHSussex) NHS Trust.

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 ran away, Brighton Magistrates’ Court heard.

On Monday, the trust pleaded guilty to failing to provide safe care and treatment resulting in avoidable harm. In mitigation, he said the acute ward was not equipped to care for vulnerable mental health patients, but the trust had accepted Ellame because of a “growing nationwide crisis” over shortages of mental health beds for children and adolescents.

The proceedings were brought by the hospital regulator, the Care Quality Commission. Her lawyer, James Marsland, said the trust had exposed Ellame “to a risk of significant and avoidable harm”.

It said its missing patient policy “provides no meaningful guidance on what to do when a vulnerable patient appears to have run away”. He said police had created confusion among staff and noted that the nurse caring for Ellame was “felt like she shouldn’t follow her.”

Marsland said Ellame had a complex diagnosis and was at risk of self-harm and running away. She tried to run away from the hospital several 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 protected, to recover and to have a fulfilling life. Her future was taken from her, and from us.”

Eleanor Sanderson, UHSussex’s lawyer, said: “The trust recognizes that the main failure was the missing patient policy of 2019. It was not clear what to do when a patient runs away. »

She said the policy should have been updated to reflect the reality that increasing numbers of mental health patients were being cared for in the children’s intensive care unit 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 uncomfortable position. She had neither the resources nor the skills to care for herself, but the alternative was to refuse to admit her.”

Separately, the trust is under police investigation for possible manslaughter of individuals and companies relating to 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 failings in maternity services.

An inquest into Ellame’s death was opened last year. The hearing was adjourned pending the outcome of the proceedings.

Ellame’s mother, supported by the charity Inquest, told the court: “The legal process is taking so long. We are still waiting for the inquest. It delays the grieving process and keeps us stuck in the details. We are surviving without living.”

She added: “There is an Ellame-shaped hole in our lives and that absence cries out every day. » Ellame had been diagnosed with dyslexia, autism and attention deficit hyperactivity disorder, and found secondary school difficult, the court heard. Her mother said she loved dancing with her younger sister and swimming in the sea with her younger brother.

“Ellame loved people and always cared more about other people’s feelings than her own,” she said.

UHSussex will be sentenced Nov. 26 for Ellame’s death. He should be given a substantial fine.