Two more deaths raise alarm over mental health in A&E

University Hospitals Sussex Foundation Trust last month admitted a charge brought by the Care Quality Commission in relation to 16-year-old Ellame Ford-Dunn, who died in February 2022 after absconding from a ward at Worthing Hospital.

Now two further similar cases have emerged, resulting in coroners issuing warnings.

The four accident and emergencies run by the trust have, in recent years, received growing numbers of emergency patients with mental health needs, sometimes spending days waiting for scarce mental health beds.

In one case, in February 2024, Mark-Anthony Summersett was taken by police to Worthing Hospital A&E, where he told reception staff he had suicidal thoughts. An hour later, when he was called for triage, the staff realised he was missing.

Coroner Joseph Turner, in a Prevention of Future Deaths report sent to the trust earlier this year, said there was a lack of shared information across agencies and teams involved in his care, “which might have enabled greater efforts to locate, contact and more urgently treat him”.

In the second case, in the same month, Patricia Genders, who had been detained under the Mental Health Act, absconded from the enhanced observation unit at the Royal Sussex County Hospital in Brighton. She left through a door that was meant to be secure.

An assistant coroner commented that communication between ward staff and security “was insufficient to locate Patricia with the necessary urgency”. If she had been followed beyond the hospital site, her death might have been prevented, he found.

In this case, a Prevention of Future Deaths report was sent to NHS England and the Department of Health and Social Care, raising concerns that a shortage of mental health beds had meant Ms Genders was at the hospital.

Wrong setting

New data last week revealed that one in 10 mental health patients who attended A&E last month waited more than 24 hours in the department, with the rate much higher in some units. The problem appeared more severe in the South East and London, with several Sussex hospitals – including the RSCH – having high rates. 

University Hospitals Sussex chief nurse Maggie Davies said: “We recognise that general hospital wards and A&E departments are not the right settings for people experiencing severe mental illness, or waiting for onward specialist mental healthcare.

“But we also accept that when such patients are in our acute hospitals, we have a responsibility to protect them, until such time as the right care becomes available. We offer our heartfelt apologies that, on rare occasions, we have not been able to do that.”

NHSE said it expressed its “deepest sympathies with Ms Gender’s family and friends” and said anyone can access crisis support through NHS 111. It had strengthened 24/7 mental health liaison services in A&Es, it said, and was rolling out mental health emergency departments.

The trust is expected to be sentenced over Ellame’s death next week. It admitted failing to provide safe care and to treatment, resulting in exposure to a significant risk of avoidable harm to a young person in its care.