A shortage of mental health beds and poor communication between agencies contributed to the death of a 16-year-old girl on hospital grounds, an inquest has found. Ellame Ford-Dunn, who had a history of self-harm, died in March 2022 after absconding from an acute children's ward at Worthing Hospital, where she had been placed due to a lack of appropriate mental health beds.
The inquest 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 also found that 'inadequate provision' of mental health beds was a contributing factor.
Coroner Joanne Andrews said she would issue a prevention of future deaths report, warning that more children would die unless the inadequate provision of mental health beds is addressed. Ellame's parents, Ken and Nancy Ford-Dunn, urged the government to increase funding for mental health services to prevent other families from experiencing similar tragedy.
The inquest heard that when Ellame absconded, staff did not immediately follow her because they were not allowed to chase patients out of the ward. It took 59 minutes for police to find her. Jurors also found that poor coordination, communication and accountability between multiple agencies contributed to her death, along with inconsistency in nursing handovers and a lack of guidance for staff.
University Hospitals Sussex, which runs the acute ward, was fined £200,000 last year in a separate prosecution over Ellame's death. Her mental health care was provided by Sussex Partnership NHS Foundation Trust. The family's lawyer, Ilaria Minucci, said the case reflects a national crisis in children's mental health services that needs urgent attention.
