NHS trust fined £200k over failings in Ellame Ford-Dunn’s death

An NHS trust has been fined £200,000 for failing to provide “safe care and treatment” to a 16-year-old girl who died on hospital grounds after fleeing its ward.

Ellame Ford-Dunn, from Upper Beeding, West Sussex, died at Worthing Hospital in March 2022, where she had been admitted as a mental health inpatient.

She ran into the hospital grounds and was not immediately attended by a nurse due to “confusion” and a lack of proper procedure, the court heard.

Last month, University Hospitals Sussex NHS Trust (UHST) pleaded guilty to failing to provide safe care and treatment to Ellame, which placed her at significant risk of “avoidable harm”.

During sentencing on Wednesday at Brighton Magistrates’ Court, District Judge Tessa Szagun said “clear instructions to follow Ellame” if she left the service “should have been incorporated” into the care plan.

Ellame was under the 24-hour individual supervision of a registered mental health nurse in an acute ward at Worthing Hospital.

She was in the ward because there was “no alternative” and “no suitable bed” for her level of risk was available, the court heard.

The prosecution admitted the trust was in a “difficult position” and should have refused Ellame otherwise.

“No level four beds were available and the high demand for such beds is a national problem,” said James Marsland, prosecuting.

Judge Szagun added: “Nothing that the defendant organization has expressed in terms of sincere apologies, condolences or regrets about the consequences of their accepted omissions, nor any fine that I impose, nor even any remarks on sentence that I make, can begin to make a difference in the way in which his family has been affected by the devastation and shock of this loss.

Speaking outside court, Ellame’s father Ken Ford-Dunn said the prosecution “recognized significant failings” in their daughter’s care.

He remembers Ellame as a “bright firework in the dark sky” and a “loving and caring soul.”

“She was deeply loved and we missed her painfully,” he added. “The loss of Ellame was devastating to all who loved her.

“There is no greater heartbreak than losing a child. But losing a child you thought was safe creates pain beyond measure and deep burning anger.”

Mr Ford-Dunn said no financial sanctions could ever “match the destruction caused”.

He also called for the money to be used by the CQC to fund children’s mental health services.

Chief Nursing Officer Dr Maggie Davies, spokesperson for UHST, said: “The loss of Ellame was a tragedy for her and those who loved her.

“Colleagues who cared for her remain devastated by her death and the impact it continues to have on her family and friends.”

Dr Davies added that when the trust appeared at last month’s hearing it “acknowledged the seriousness of what happened” and the “devastating impact” on Ellame’s family and friends.

“That remains true today,” she added.

“We had a responsibility to protect her while she was in our care, and we are sincerely sorry that we were not able to do so.

“Everyone agrees that people with acute mental illness should not be on general hospital wards or emergency departments, but that does not diminish our duty to keep patients safe while efforts are made to provide them with more appropriate care.”

Dr Davies added that since Ellame’s death the trust had made “significant improvements” to its policies, training and service environment to “prevent something like this from happening again”.

The judge fined UHST £200,000 which it will pay to the Care Quality Commission, along with prosecution costs and a victim surcharge of £190.

Additional reporting by PA.

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