An NHS trust has been fined £200,000 after admitting it failed to provide safe care and treatment to a 16-year-old girl who died after absconding from an acute children’s ward at Worthing hospital.
University Hospitals Sussex NHS Foundation Trust (UHSussex) was sentenced at Brighton magistrates’ court on Wednesday over the death of Ellame Ford-Dunn in March 2022. Her parents said their daughter had been “failed by a system that was meant to protect her” and called on ministers to overhaul children’s mental health services and ensure money from the fine is channelled into improving care.
The trust pleaded guilty to offences under regulations 12 and 22 of the Health and Social Care Act 2008, relating to failures to provide safe care and exposing a patient to a significant risk of avoidable harm. District judge Tessa Szagun imposed a £200,000 fine, £25,405.70 in prosecution costs and a £190 victim surcharge, all payable to the Care Quality Commission (CQC). No compensation order was made for the family, who are pursuing a separate civil claim.
Sentencing, Szagun described the circumstances as “tragic” and said no level of fine or apology could match the “devastation and shock” suffered by Ellame’s family. She found that clear instructions to staff to follow the teenager if she left the ward “should have been” included in her care plan and that the hospital had failed to adapt to a known risk of absconding.
The criminal case was brought by the CQC, which found that UHSussex knew Ellame had a history of running away and self-harm but “failed to manage this known risk adequately”. Its investigation concluded the trust’s 2019 missing-patient policy contained no meaningful guidance on what staff should do if a vulnerable patient was seen leaving a ward. Prosecutors argued it was not “reasonably practicable” for the trust to omit a requirement to follow such a patient, given the obvious danger.
On the evening of 20 March 2022, Ellame was on Bluefin ward, an acute paediatric ward at Worthing hospital, under one-to-one observation by an agency mental health nurse. Just after 8.30pm, she walked off the ward. The nurse watched her leave but did not follow, later telling investigators she believed the trust’s policy prevented her from leaving the ward after an absconding patient. Security staff began searching the site and police were called. About an hour later, officers found Ellame on the hospital grounds after she had used a ligature. She was returned to the hospital but died shortly afterwards.
The court heard that Ellame was autistic, had ADHD and an eating disorder, and had a long history of trauma, suicidal ideation and self-harm. She had spent more than 18 months in specialist child and adolescent mental health services (CAMHS) inpatient units before being discharged from Chalkhill hospital in January 2022 with a community aftercare package. In late February she was admitted informally to Bluefin ward following self-harm, despite it not being a specialist psychiatric unit. Within days she absconded and ligatured, after which she was detained under section 3 of the Mental Health Act and placed on 24-hour one-to-one observation. Both the trust and regulator accepted that by this point her risk of absconding and serious self-harm was well known.
Outside court, her father, Ken Ford-Dunn, described his daughter as “a bright firework in a dark sky” and said no financial penalty could ever feel proportionate to the “destruction” caused by her death. He and her mother, Nancy, said “the system” rather than a single individual had failed her, pointing to the use of a general children’s ward for a highly complex psychiatric case, a policy that discouraged staff from following absconding patients and a national shortage of specialist beds. Nancy said Ellame “deserved to be kept safe and get well” and that since her death the family had been “surviving, not living”.
The family have urged the government to reform children’s mental health provision and to ensure the money from the fine is reinvested directly into services for young people, rather than disappearing into regulatory budgets. An inquest into Ellame’s death has opened but was adjourned pending the completion of the criminal proceedings and is expected to examine her care from January to March 2022, including risk assessments, observation levels and the trust’s missing-patient policy.
UHSussex’s chief nurse, Dr Maggie Davies, issued an unreserved apology, calling the loss of Ellame “a tragedy” and saying staff were “devastated” they had not been able to protect her. “We had a responsibility to protect her,” she said. “We are sincerely sorry we were not able to do that.” The trust accepted that its missing-patient policy was a “core failing” and said it has since been replaced. Under new procedures, staff are instructed to take reasonable steps to stop a patient leaving, raise the alarm, follow them while trying to persuade them to return, record their direction of travel and call police if there is an immediate risk.
The charity INQUEST, which is supporting the family, said the penalty was understood to be the fifth-largest fine imposed on an NHS or private provider following a death in a mental health setting and reflected the seriousness of the failings. It argued, however, that fines alone would not address what it called systemic problems across mental health and acute hospital services.
Ellame’s case comes amid mounting concern over children being cared for on general wards because of a lack of specialist CAMHS beds. Regulators have reported record numbers of open referrals for young people’s mental health support and a sharp rise in admissions of children to acute hospitals in crisis. In Sussex, the only Tier 4 CAMHS inpatient unit, Chalkhill in Haywards Heath, is facing temporary closure following critical inspections, raising fears that more high-risk patients will be managed on non-specialist wards or sent far from home.