University Hospitals Sussex NHS Foundation Trust pleaded guilty today (October 27) in Brighton Magistrates’ Court to failing to give safe care and treatment, resulting in avoidable injury to a young person in its care.

The Care Quality Commission brought the complaint. The hospital trust is likely to face a significant fine.

The court heard that the adolescent had made repeated escapes from the unit and attempted to ligature herself before being discovered by personnel.

However, on March 20, the court heard Ellame was not pursued for 90 seconds because the agency nurse she was with did not immediately follow her, instead informing other staff because she had been instructed not to follow during handover.

The CQC’s prosecutor, James Marsland, stated that their uncertainty was “a symptom of the failure to have a policy directive that such vulnerable patients ought to be followed immediately,” which has now been revised.

He stated, “The trust failed to provide Ellame with safe care and treatment by not doing everything that was reasonably practicable.”

“Namely that there was no adequate guidance to staff to follow a patient seen to abscond from the ward.” The hospital trust admitted that its’missing person’ policy was not explicit enough, resulting in uncertainty, and that this was a failure on its behalf.

By the time security and personnel began looking for Ellame, the court heard they proceeded in the incorrect direction. That evening, police officers discovered the teenager near the hospital grounds.

Ellame would not normally have been admitted to the UHST ward, but the Sussex Partnership Foundation Trust (SPFT), who were assessing her condition, were unable to provide her with an appropriate bed for her risk classification.

It was said that the young girl had no choice but to remain aboard Bluefin, despite the fact that staff were neither trained or equipped to handle her demands. It was reported that the only other choice would have been to refuse Ellame care.

Ellame was discharged from Chalkhill Hospital in Haywards Heath on January 18, 2022, and will receive community care. However, on February 28, she was informally admitted to Bluefin for self-harm.

A few days later, she was held under Section 3 of the Mental Health Act for fleeing the institution and ligaturing.

“The prosecution accepts that in that particular regard the defendant trust was in a difficult position; there was no immediately available alternative at the time of admitting Ellame to Bluefin Ward,” according to Marsland.

He elaborated: “No tier four was readily available and the high demand for such beds is a national issue.”

A “tier four” is a specialised unit for young people who have serious mental health issues. Ellame was subjected to one-on-one 24-hour observations.

During the court hearing, it was stated that A&E departments around the country are seeing an increase in the number of young people arriving with mental health issues.

Maggie Davies, head nurse at University Hospitals Sussex NHS Foundation Trust, said: “Ellame’s death was a tragedy for her and everyone who loved her. Her death has grieved those involved in her care, as has the impact on her family and friends.

“Everyone agrees that people with acute mental illnesses should not be in general hospital wards or A&E departments, but we had a responsibility to protect her while she was in our care, and we sincerely apologise for not being able to do so.”

“Ever since Ellame’s death, we have acknowledged that our’missing person’ policies and training were not explicit enough. We highlighted this, made modifications, and now accepted the single charge related to that policy.

“We are committed to working with our partners to ensure there are better ways to care for people who are at a point of such vulnerability and distress.” The court was deferred until November 26 for sentencing.

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