Inquest finds bed shortage and poor communication contributed to teenager's death
A critical shortage of mental health beds and significant failures in communication between healthcare agencies directly contributed to the tragic death of a teenage girl on hospital grounds, a coroner's inquest has determined.
Ellame Ford-Dunn, a 16-year-old with a history of self-harm, died in March 2022 after absconding from an acute children's ward at Worthing Hospital. The inquest heard she had been placed there due to a complete lack of appropriate specialist mental health beds.
Systemic failures exposed
The jury at West Sussex Coroner's Court concluded that the decision to place Ellame on the Bluefin ward, which was not a specialist mental health unit, was "inappropriate" and "more than minimally" contributed to her death. They found "inadequate provision" of mental health beds was a key factor.
Coroner Joanne Andrews stated she would issue a prevention of future deaths report, warning that more children would die unless the chronic shortage of mental health beds was urgently addressed.
Multiple absconding incidents
During the inquest, it emerged that Ellame had absconded "multiple times" during her stay at Worthing Hospital. When she absconded for the final time, staff did not immediately follow her because they were not permitted to chase patients beyond the ward boundaries.
It took police 59 minutes to locate Ellame after her final disappearance from the hospital premises.
Communication breakdowns
The jury identified serious communication failures between the multiple agencies involved in Ellame's care. They concluded that "poor coordination, communication and accountability" between organisations contributed significantly to her death.
Specific findings included:
- Inconsistent nursing handovers between shifts
- Inadequate instructions given to agency-registered mental health nurses
- Patient notes held on multiple systems with limited access for agency staff
- Unclear procedures for managing high-risk mental health patients who abscond
Family's plea for change
Ellame's parents, Ken and Nancy Ford-Dunn, have urged the government to increase funding for mental health services to prevent other families experiencing similar tragedies.
In a statement, they said: "The devastation of our daughter's death would be compounded if no lessons are learnt and no meaningful changes are made, as so often has been the case."
They called specifically for NHS England and Health Secretary Wes Streeting to increase funding, and for Sussex Partnership NHS Foundation Trust to create effective specialist provision for young people with mental health needs.
Broader systemic issues
Jodie Anderson, senior caseworker at the charity Inquest which supported the family, described a mental health system "crumbling at the seams" in Sussex. She highlighted how a lack of specialist beds and dismissive responses to Ellame's distress left her in an unsuitable paediatric ward.
University Hospitals Sussex, which runs the acute ward where Ellame was placed, was fined £200,000 last year in a separate prosecution related to her death. Her mental health care was provided by Sussex Partnership NHS Foundation Trust.
The family's lawyer, Ilaria Minucci of Birnberg Peirce, emphasised that Ellame's case reflects "a crisis at the national level" in children's mental health services that requires urgent attention.
