The heartbroken parents of a teenage girl have spoken of their devastation after their daughter died while receiving mental health treatment in hospital. Ellame Ford-Dunn, aged just 16, took her own life in March 2022 after absconding from the Bluefin paediatric ward at Worthing Hospital.
Systemic Failures Exposed by Inquest
A recent inquest into Ellame's tragic death has revealed a catalogue of systemic failures that contributed to the teenager's passing. The jury concluded that it was inappropriate for Ellame to be detained on a paediatric ward from February 28 to March 20, 2022, noting that risk assessments were inadequate and inconsistently applied throughout her stay.
Critical Communication Breakdowns
Jurors identified poor coordination, communication, and accountability between multiple agencies as significant factors in Ellame's death. The teenager's mental health care was provided by Sussex Partnership NHS Foundation Trust, while the Bluefin Ward where she was placed fell under the management of University Hospitals Sussex NHS Foundation Trust.
The jury foreman stated: "The instructions given to agency-registered mental health nurses were inadequate, patient notes were held on multiple systems, with access not freely available to agency staff and inadequately transferred during handover."
Parents' Anguish and Determination
Ellame's mother, Nancy Ford-Dunn, expressed her profound grief and determination to prevent similar tragedies. "I can't brush her hair and paint her nails and wash her clothes," she told the inquest. "I can't do all those parenting things that I want to be able to do, so all we've got left is this fight to make sure that everyone understands how badly she was failed."
Her father, Ken Ford-Dunn, described the overwhelming emotions following their loss: "It's hard to explain because you have the devastation, you have the overwhelming, it's almost like fear of the sadness, that personally I can't quite connect with because I've got so much anger towards the services that failed her. So much."
Multiple Attempts to Escape
The inquest heard that Ellame had tried to run away "multiple times" during her stay on the Bluefin ward, which was not a specialist mental health facility. When she finally absconded on March 20, staff did not immediately follow her, and it took police 59 minutes to locate her.
The decision to detain Ellame on the ward without adequate security provision was found to have contributed to her death. University Hospitals Sussex NHS Foundation Trust's policy for missing patients was not designed for high-risk mental health patients, and procedures to follow in the event of absconsion were unclear and poorly communicated to staff.
Broader Systemic Issues Revealed
The inquest uncovered that Ellame was placed on an acute paediatric ward due to a lack of available specialist mental health beds. Area coroner Joanne Andrews has ordered a prevention of future deaths report from NHS England after hearing evidence that numerous young people continue to be held on acute paediatric wards while waiting for mental health beds to become available.
In November last year, University Hospitals Sussex NHS Foundation Trust was fined £200,000 after admitting failing to provide safe care and treatment to Ellame, which exposed her to significant risk of avoidable harm.
Trust Responses and Apologies
Dr Maggie Davies, chief nurse for University Hospitals Sussex NHS Foundation Trust, expressed deep remorse: "The loss of Ellame at such a young age was a tragedy and devastating for everyone who knew and loved her. We had a responsibility to protect her while she was in our care and we are deeply sorry that we were not able to do so."
The trust states it has "fundamentally improved" its care since Ellame's death. Dr Richard Sankar, clinical director for the NHS-led Hampshire, Isle of Wight, Sussex, Kent and Medway Child and Adolescent Mental Health Services Provider Collaborative, acknowledged delays in identifying a mental health bed for Ellame and offered sincere condolences to her family.
Ongoing Concerns and Future Actions
The coroner has requested evidence from both trusts about improvements they have implemented to their communication and report sharing systems. Ellame's mother told jurors that the family did not feel properly supported by social services and healthcare providers during their daughter's treatment.
Ellame had been diagnosed with autism, ADHD and dyslexia, and began struggling with her mental health when she started secondary school. She had previously been an inpatient on mental health wards but was released to live with her parents in January 2022, just months before her tragic death.
