Ellame Ford-Dunn died in the grounds of Worthing Hospital where she had been admitted as a mental health inpatient in March 2022.

Brighton Magistrates' Court heard Ellame had been under 24-hour one-to-one supervision on an acute ward by a registered mental health nurse when she absconded because there was ‘no alternative' and no adequate bed for her risk level was available.

Helen Rawlings, CQC director of operations in the South, said: ‘Ellame should have been able to rely on University Hospitals Sussex NHS Foundation Trust to take all the steps they could to keep her safe during a very vulnerable time in her life, but this didn't happen. 

‘The trust was aware of Ellame's history of absconding, yet failed to manage this known risk adequately, which might have avoided this tragic outcome.  

 

‘The prosecution should remind all health and social care organisations of their duty to provide care that meets people's needs and reduces the risks to their safety based on their individual circumstances.'

Maggie Davies, chief nurse at University Hospitals Sussex said: ‘The loss of Ellame was a tragedy, for her and those who loved her. Colleagues involved in her care are devastated by her death and the impact it continues to have on her family and friends.

‘Everyone accepts that people with acute mental illness 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 offer our heartfelt apologies for not being able to do that.

‘Ever since Ellame's death we have agreed that our "missing person" policy, and training around it, was not clear enough. We highlighted that, made improvements, and today we accepted the single charge relating 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.'

Sentencing will take place on 26 November.