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 escaping from her room.

Ellam Ford-Dunn, from Upper Beeding, West Sussex, died at Worthing Hospital in March 2022, where she had been admitted to a psychiatric hospital.

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

Last month University Hospitals of Sussex NHS Trust (UHST) pleads guilty of failing to provide Ellam with safe care and treatment, which exposed her to a significant risk of “avoidable harm.”

At Wednesday's sentencing at Brighton Magistrates' Court, District Judge Tessa Sagun said “clear instructions to follow Elleim” if she left the ward “should have been included” in the care plan.

Elleim was under 24-hour individual supervision by a registered mental health nurse in Worthing Hospital's emergency department.

The court heard she was in that ward because there was “no alternative” and “there was no suitable bed” for her risk level.

The prosecution acknowledged that the fund was in a “difficult position” and would otherwise have had to refuse Ellam.

“The fourth tier was not available and the high demand for such beds is a national problem,” said James Marsland, prosecuting.

Judge Sagun added: “Nothing that the defendant organization has expressed by way of sincere apologies, condolences or regrets for the consequences of its failures to act, nor any fine that I impose, or even any remarks about the sentence that I make, can have any bearing on the impact on her family of the devastation and shock of this loss.”

Speaking outside the court, Ellam's father Ken Ford-Dunn said the prosecution had “admitted significant failings” in their daughter's care.

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

“She was greatly loved and greatly missed,” he added. “The loss of Elleme has been devastating to everyone who loved her.

“There is no greater grief than losing a child. But losing a child you believed was safe causes immense pain and deep, burning anger.”

Mr Ford-Dunn said no financial penalty could ever “compared to the damage caused”.

He also called on the CQC to use the money to fund children's mental health services.

Chief nurse Dr Maggie Davies, UHST, said: “The loss of Elleim 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 that when the trust appeared at the hearing last month it “acknowledged the seriousness of what happened” and the “devastating impact” on Ellam'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 truly sorry we were unable to do so.

“Everyone recognizes that people with acute mental illness should not be on general hospital wards or emergency departments, but this does not diminish our responsibility to keep patients safe while working to provide them with more appropriate care.”

Dr Davies added that since Ellam's death the trust had made “significant improvements” to its policies, training and ward conditions to “prevent this from happening again”.

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

Additional PA reporting.

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