System 'failed' our daughter, say parents - as NHS trust fined over death of girl, 16

Ellame Ford-Dunn, 16, died after absconding and ligaturing in the grounds of Worthing Hospital while she was a mental health inpatient on March 20 2022.

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.

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".

On Wednesday at Brighton Magistrates' Court, District Judge Tessa Szagun said that "clear instructions to follow Ellame" if she left the ward "should have been incorporated" into the ward's care plan.

Judge Szagun said: "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."

The Judge fined UHST £200,000 which they will pay to the Treasury, along with prosecution costs and a victim surcharge of £190.

Judge Szagun noted that she had "not been asked" to deal with compensation for Ellame's family, many of whom were sitting in court.

Outside court, her father Ken Ford-Dunn said their daughter was "failed by a system that was meant to protect her".

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

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

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 that the defendant 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.

Ellame would not usually have been on the UHST ward but Sussex Partnership Foundation Trust (SPFT), who were assessing her condition, did not have capacity to provide her with an adequate bed.

Judge Szagun said: "In my judgment, what is of course expected and required of any organisation entrusted with the care of amongst the most vulnerable in society, is that they should be alert to and proactive to changes in advice and guidance.

"That should have covered the recognition of the increased pressures and demands being placed on such wards by the need for them to accommodate the more risky and needy patients such as Ellame."

Outside court, Ellame's father remembered her as "a bright firework in a dark sky" and said he still feels a "deep searing anger".

He said: "The loss of Ellame has been devastating, not only for us as a family, but for her wider family, friends and all who loved her.

"There is no greater heartbreak than losing a child, but to lose a child you believed was being kept safe creates a pain beyond measure, and a deep, searing anger. "

No financial penalty could ever feel proportionate to the destruction that has been caused."

'Tragedy'

Chief nurse at UHST, Maggie Davies said: "When we appeared at last month's hearing, we acknowledged the seriousness of what happened and the devastating impact on Ellame's family and friends. That remains true today.

"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.

"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.

"Since Ellame's death, we have made significant improvements to our policies, training, and ward environments to prevent anything like this happening again.

"Today's sentencing reflects the seriousness of what happened, and we remain committed to working with our NHS partners to learn from this tragedy, and for us all to find better ways of caring for patients who are vulnerable."