A girl who killed herself when she absconded from 24-hour clinical supervision was failed by a system that was meant to protect her, her parents have said, after the NHS trust involved was fined over the avoidable death.
Ellame Ford-Dunn, 16, who suffered with severe mental health problems, died on 20 March 2022, minutes after leaving the Bluefin acute children’s ward in Worthing hospital, part of University hospitals Sussex NHS trust (UHSussex).
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 absconded, Brighton magistrates court was told last month.
On Wednesday the trust was fined £200,000 plus costs by the district judge Tessa Szagun for criminal health and safety offences over Ellame’s death.
Her parents, Nancy and Ken Ford-Dunn, said the prosecution, which was brought by the hospital regulator the Care Quality Commission, confirmed that their daughter had been “failed by a system that was meant to protect her”.
The trust had pleaded guilty to a failure to provide safe care and treatment resulting in avoidable harm. In mitigation it said the ward was not equipped to deal with vulnerable mental health patients but that the trust had accepted Ellame amid a national shortage of mental health beds for children and adolescents.
Judge Szagun said: “Any organisation entrusted with the care of amongst the most vulnerable in society … 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.”
Ellame’s parents expressed fury at trust’s failure to prevent their daughter’s death. In a statement read outside the court, her father, Ken, said: “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.”
He urged the government to use the fine to improve children’s mental health provision. “No financial penalty could ever feel proportionate to the destruction that has been caused. We would take some comfort were the secretary for health to direct the funds toward strengthening children’s mental health services, an area in such urgent need of support.”
The family is pursuing a separate claim for damages against the trust. Ellame’s mother added: “We do not want to say more at this stage as we do not want to risk jeopardising the ongoing legal proceedings. This prosecution is an important step in highlighting just one of the many failings in Ellame’s care and brings a first taste of justice on behalf of our darling girl.”
Jodie Anderson, a senior caseworker at the charity Inquest, which has been supporting the family, said: “We need urgent action to ensure further failures and harms by mental health services are prevented, and to ensure every child and young person in distress receives the care and support they need.”
At last month’s hearing the trust pleaded guilty to a failure to provide safe care and treatment, resulting in avoidable harm. Eleanor Sanderson, the counsel for UHSussex, told the hearing: “The trust accepts the core failing was the 2019 missing patient policy. It wasn’t clear about what to do when a patient absconds.”
An inquest into Ellame’s death opened last year. It was adjourned pending the outcome of the prosecution.
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
