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” for a 16-year-old girl who died on hospital grounds after fleeing her 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 grounds of the hospital and was not immediately followed by a nurse because of “confusion” and a lack of appropriate procedure in place, the court heard.

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

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

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 accepted the trust was in a “difficult position” and would have had to turn Ellame away otherwise.

“No tier four was readily available and the high demand for such beds is a national issue,” said James Marsland, prosecuting.

Judge Szagun added: “Nothing that the defendant organisation expressed in terms of their heartfelt apology and condolence or regret at the consequences of their accepted omissions, nor any fine I impose, or indeed any sentencing remarks I make, can begin to make any difference to how her family have been impacted by the devastation and shock of this loss.”

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

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

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

“There’s no greater heartbreak than losing a child. But to lose a child that you believed was being kept safe, creates a pain beyond measure and a deep searing anger.”

Mr Ford-Dunn said no financial penalty could ever “match the destruction that has been caused”.

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

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

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

Dr Davies added 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 that.

“Everyone accepts that people with acute mental illness should not be in general hospital wards or A&E departments, but that does not lessen our duty to keep patients safe whilst efforts are made to provide them with more appropriate care.”

Dr Davies added since Ellame’s death, the trust had made “significant improvements” to its policies, training and ward environments to “prevent anything like this happening again”.

The judge fined UHST £200,000 which they 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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