An NHS trust has pleaded guilty to failures contributing to the avoidable death of a 16-year-old girl who killed herself after leaving a hospital ward without supervision. Ellame Ford-Dunn, who had severe mental health problems, died on 20 March 2022, minutes after walking out of the Bluefin acute children’s ward at Worthing Hospital, part of University Hospitals Sussex NHS trust (UHSussex).
Brighton magistrates court heard that an agency nurse watched Ellame leave the ward but did not follow her, believing she had been instructed not to leave the ward if a patient absconded. The prosecution, brought by the Care Quality Commission, said the trust’s policy on missing patients failed to provide meaningful guidance on how to respond when a vulnerable patient was seen leaving.
UHSussex admitted a failure to provide safe care and treatment resulting in avoidable harm. In mitigation, the trust said the acute ward was not equipped to care for vulnerable mental health patients, but Ellame had been accepted due to a national shortage of child and adolescent mental health beds. The trust’s counsel said the 2019 missing patient policy should have been updated to reflect that reality.
Ellame had a complex diagnosis and was at risk of self-harm and absconding, having attempted to leave the hospital several times in the weeks before her death. In a victim impact statement, her 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.” She added that the legal process had delayed grieving, leaving “an Ellame-shaped hole in our lives”.
Separately, the trust is under police investigation for possible corporate manslaughter over more than 90 deaths involving alleged negligence in surgery, and is one of 14 trusts subject to a national inquiry into maternity failings. An inquest into Ellame’s death has been adjourned. UHSussex is due to be sentenced on 26 November, with a substantial fine expected.
