Before HM Coroner Joanne Andrews
Chart Way Horsham West Sussex RH12 1XH
Opened and adjourned October 2024
26 January - 2 February 2026
Ellame Ford-Dunn (pronounced ‘El-Ah-Me’), was 16 years old when she died after absconding and ligaturing whilst a mental health inpatient at Worthing Hospital. Now a jury has found that a series of failings including the inadequate provision of beds for children with mental ill health in Sussex contributed to Ellame’s death.
Last November, University Hospitals Sussex NHS Foundation Trust (UHST) was fined £200,000 after admitting to health and safety offences relating to Ellame’s death. INQUEST understands this to be the fifth largest fine imposed on an NHS Trust or private provider following a death in a mental health setting.
Ellame was the eldest of three children. She loved swimming in the sea with her brother and dancing with her sister. Her family describe her as a people pleaser who always cared more about other people’s feelings than her own.
Ellame had a long history of trauma, suicidal ideation and self-harm. She was autistic and had ADHD, PTSD and an eating disorder. She was under the care of Child and Adolescent Mental Health Services (CAMHS) and had spent over 18 months in inpatient mental health care units.
On 18 January 2022, Ellame was discharged from Chalkhill Hospital with s.117 aftercare which should have provided care for her in the community, in order to prevent a further hospital admission. The jury heard that the proposed care package was not fully implemented by 18 January. The care plan included DBT (Dialectical Behaviour Therapy), but this was not accessible to Ellame upon discharge; and only became available to her in early February 2022.
A psychiatrist was allocated to Ellame to supervise her following her discharge, but Ellame only met her psychiatrist for the first time two weeks after her discharge.
Mental health professionals accepted that Ellame’s parents carried a substantial share of the responsibility for her care in the community. Ellame’s parents faced difficulties managing her risk, particularly in the evening, and they requested for respite support to assist so that Ellame could remain safely at home. By the time evening support was identified, Ellame had already been admitted to Bluefin Ward.
During this period there was an escalation of Ellame’s risk to herself including increased self-harming, such as ligaturing and the restriction of her food intake, some of which led to temporary hospital admissions.
On 28 February 2022, Ellame was informally admitted to Bluefin Ward at Worthing Hospital as a result of self-harm.
The jury heard evidence that Ellame was at high risk of suicide, self-harm and absconding, for the entirety of her final admission. From the date of her re-admission on 28 February, Ellame experienced further absconding and self-harming incidents.
The inquest heard of the inadequacy of the risk assessments, incomplete documentation about risk and lack of proper information-sharing to RMNs allocated to provide 1:1 care to Ellame. There was no system in place for registered mental health nurses (RMN) allocated to provide 1:1 supervision to Ellame to have straightforward access to relevant information concerning her risk and recent self-harming.
In March 2022, Ellame was formally detained under Section 3 of the Mental Health Act after absconding and ligaturing, following a mental health assessment. Despite these concerns, the jury heard that Ellame did not see a psychiatrist again following this assessment. She was placed under 24-hour one-to-one observation by a RMN.
The jury heard that all the agencies involved in her care were aware of the attempts that Ellame had made to abscond whilst on Bluefin Ward, but no other changes to her care provisions were made. No security arrangements were formulated to manage the risk of absconding and keep Ellame safe.
The day before Ellame’s death, the nurse allocated to her 1:1 supervision of Ellame unexpectedly left her. Also, in the early hours of 20 March Ellame had another ligaturing incident. The jury heard from the RMN assigned to Ellame’s 1:1 supervision in the evening of 20 March 2022 that she had not been made aware of these two crucial events until after Ellame’s passing.
At 8.30pm on 20 March 2022, Ellame absconded from her RMN.
The evidence has been that Worthing Hospital’s missing person policy at the time was not formulated to give directions to hospital staff if a young person absconded. Despite having been rated as being at high risk of absconding, there was no clear plan on Bluefin Ward about what staff should do if Ellame (or another high-risk vulnerable mental health patient) absconded.
If Ellame absconded from the Ward, the hospital’s policy on absconding patients required staff to fast bleep security and follow the patient to the doors of the hospital, but no further. The inquest also heard evidence that neither RMN nor Bluefin Ward staff were permitted to chase after a patient who had absconded from the Ward.
Security officers and some nursing staff performed a search of the hospital grounds before informing Sussex police.
At 9.30pm, police found Ellame having ligatured in the hospital grounds. An ambulance was called and Ellame was taken into the hospital where she was declared dead shortly after.
Jury conclusions
The jury found that the medical cause of Ellame’s death was asphyxiation due to a ligature, though it was not possible to know if she had intended to take her own life. They also concluded that her condition of PTSD has more than minimally contributed to her death.
They also found the following failures to have more than minimally contributed to her death:
- Inadequate provision of Tier 4 beds for children with severe mental health difficulties in Sussex and nationally.
- The decision to detain Ellame on an acute paediatric ward without the provision of security.
- The inconsistency of nursing handovers and little guidance on how to plan or respond if risk escalated or if Ellame absconded.
- Poor co-ordination, communication and accountability between multiple agencies providing care for Ellame.
The Coroner indicated that she will be issuing a Prevention of Future Deaths (PFD) report to NHS England concerning the use of acute paediatric wards for children and young people requiring specialist psychiatric support.
In addition to this, the Coroner is considering a further PFD and has requested additional statements.
Ellame’s parents said:“Nothing can compare to the devastation that we feel at the loss of Ellame.
This will be further compounded if no lessons are learnt and no meaningful changes are made, as so often has been the case.
We therefore call on NHS England and Wes Streeting to increase funding for mental health services so that more young people aren’t left waiting for the care that they so desperately need, and other families don’t have to experience the worst thing imaginable, the death of their child.
We call on SPFT to create effective specialist provision for young people with mental health needs who are currently still inappropriately placed, like Ellame was, on local paediatric wards that are not set up to provide safe and positive mental health care."
Jodie Anderson, Senior Caseworker at INQUEST, said: “Ellame’s inquest has exposed a mental health system in Sussex that is crumbling at the seams.
A lack of specialist beds and a dismissive response to Ellame’s distress left her to languish in an unsuitable paediatric ward. A lack of urgency and professional curiosity was endemic throughout her care.
Too many families like Ellame’s have been failed by Sussex mental health services. Their collective fight for a system which responds with care and support to the distress of children and young people should inspire and compel us all to action. Lives are at stake.”
Ilaria Minucci of Birnberg Peirce said: “My clients are grateful to HM Coroner and the jury for their careful consideration of the crucial issues in this case. Sadly, Ellame’s story is an irreparable tragedy for her family, and they will bear the loss of Ellame for the rest of their lives.
Ellame’s case needs to remind us that stories like hers are not isolated instances, and that they reflect a crisis at the national level in respect of children’s mental health services that needs to be dealt with urgently.”
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Leila Hagmann on leilahagmann@inquest.org.uk.
The family are represented by INQUEST Lawyers Group members Ilaria Minucci of Birnberg Peirce and Oliver Lewis of Doughty Street. They are supported by INQUEST Senior Caseworker Jodie Anderson.
Other Interested persons represented are Sussex Partnership NHS Foundation Trust (SPFT), University Hospitals Sussex NHS Foundation Trust (UHSFT), a Registered Mental Health Nurse (RMN), West Sussex County Council, the Care Quality Commission (CQC), and the NHS Integrated Care Board (ICB).
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Deaths in the care of Sussex mental health services:
- Morgan Betchley was 19 years old when she died after ligaturing whilst a voluntary mental health inpatient at Meadowfield Hospital on 9 March 2023. An inquest found that a series of failings and unprofessional behaviour by staff contributed to Morgan’s death. Media release.
- Morghana Woodburn, 18, died a self-inflicted death at Meadowfield Hospital in January 2018. Morghana was diagnosed with PTSD and EUPD. She was moved seven times between four different hospitals over the nine months leading up to her death. An inquest concluded that she died as a result of her mental health issues which led her to self-harm. Media coverage.
- Matty Sheldrick, a 29 year old autistic person, died on 22 November 2022 after ligaturing outside the Royal Sussex County Hospital. They had left A&E less than two hours before. An inquest into their death resumed this week. Media release.
- Jason Pulman, a 15 year old transgender teenager died a self-inflicted death on 19 April 2022 in East Sussex. An inquest found that systemic failures by all of the organisations involved in his care, with the exception of his school, possibly contributed to his death. Media release.
- Jessie Eastland Seares, 19, died whilst an inpatient at Mill View Hospital in May 2022. Jessie was autistic and had a complex history of neurodevelopmental, physical and mental health issues. A jury found that systemic failures in health and social care led to her death. Media release.
- Rachel Garrett, 22, died after falling from a height in Brighton on 29 July 2020. An inquest found that opportunities to save her life had been missed. Rachel had mental and physical health needs and had spent time in the care of Mill View Hospital. Media release.
- The Telegraph reported in January 2022 that more than 360 patients took their own lives after being treated by Sussex Partnership Foundation NHS Trust in the past five years. While there were also 15 coroner’s reports to prevent future deaths.
- Bethany Tenquist, 26, died after ligaturing in her room at Mill View Hospital on 16 January 2019. An inquest found a sequence of serious failures relating to staffing, leadership and safeguarding processes on ward probably had a direct causal connection to her death. Media release.
- Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care. Media release.
- In 2016, local media reported that five women had died at Mill View Hospital, including Janet Müller (above), Danuta Corbett, Jessica Philpott, Jackie Stansby, and Philippa Mortiz-Parsons.
- Sabrina ‘Sabby’ Walsh, 32, died on the Woodlands Ward in Sussex 2016. The inquest found gross failures and neglect contributed to her death. Media release.
- Bethan Smith, 31, died whilst under the care of Sussex Partnership Trust in 2011. Her mother wrote this about their experiences.
INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
Ellame Ford-Dunn
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Before HM Coroner Joanne Andrews
Chart Way Horsham West Sussex RH12 1XH
Opened and adjourned October 2024
26 January - 2 February 2026
Ellame Ford-Dunn (pronounced ‘El-Ah-Me’), was 16 years old when she died after absconding and ligaturing whilst a mental health inpatient at Worthing Hospital. Now a jury has found that a series of failings including the inadequate provision of beds for children with mental ill health in Sussex contributed to Ellame’s death.
Last November, University Hospitals Sussex NHS Foundation Trust (UHST) was fined £200,000 after admitting to health and safety offences relating to Ellame’s death. INQUEST understands this to be the fifth largest fine imposed on an NHS Trust or private provider following a death in a mental health setting.
Ellame was the eldest of three children. She loved swimming in the sea with her brother and dancing with her sister. Her family describe her as a people pleaser who always cared more about other people’s feelings than her own.
Ellame had a long history of trauma, suicidal ideation and self-harm. She was autistic and had ADHD, PTSD and an eating disorder. She was under the care of Child and Adolescent Mental Health Services (CAMHS) and had spent over 18 months in inpatient mental health care units.
On 18 January 2022, Ellame was discharged from Chalkhill Hospital with s.117 aftercare which should have provided care for her in the community, in order to prevent a further hospital admission. The jury heard that the proposed care package was not fully implemented by 18 January. The care plan included DBT (Dialectical Behaviour Therapy), but this was not accessible to Ellame upon discharge; and only became available to her in early February 2022.
A psychiatrist was allocated to Ellame to supervise her following her discharge, but Ellame only met her psychiatrist for the first time two weeks after her discharge.
Mental health professionals accepted that Ellame’s parents carried a substantial share of the responsibility for her care in the community. Ellame’s parents faced difficulties managing her risk, particularly in the evening, and they requested for respite support to assist so that Ellame could remain safely at home. By the time evening support was identified, Ellame had already been admitted to Bluefin Ward.
During this period there was an escalation of Ellame’s risk to herself including increased self-harming, such as ligaturing and the restriction of her food intake, some of which led to temporary hospital admissions.
On 28 February 2022, Ellame was informally admitted to Bluefin Ward at Worthing Hospital as a result of self-harm.
The jury heard evidence that Ellame was at high risk of suicide, self-harm and absconding, for the entirety of her final admission. From the date of her re-admission on 28 February, Ellame experienced further absconding and self-harming incidents.
The inquest heard of the inadequacy of the risk assessments, incomplete documentation about risk and lack of proper information-sharing to RMNs allocated to provide 1:1 care to Ellame. There was no system in place for registered mental health nurses (RMN) allocated to provide 1:1 supervision to Ellame to have straightforward access to relevant information concerning her risk and recent self-harming.
In March 2022, Ellame was formally detained under Section 3 of the Mental Health Act after absconding and ligaturing, following a mental health assessment. Despite these concerns, the jury heard that Ellame did not see a psychiatrist again following this assessment. She was placed under 24-hour one-to-one observation by a RMN.
The jury heard that all the agencies involved in her care were aware of the attempts that Ellame had made to abscond whilst on Bluefin Ward, but no other changes to her care provisions were made. No security arrangements were formulated to manage the risk of absconding and keep Ellame safe.
The day before Ellame’s death, the nurse allocated to her 1:1 supervision of Ellame unexpectedly left her. Also, in the early hours of 20 March Ellame had another ligaturing incident. The jury heard from the RMN assigned to Ellame’s 1:1 supervision in the evening of 20 March 2022 that she had not been made aware of these two crucial events until after Ellame’s passing.
At 8.30pm on 20 March 2022, Ellame absconded from her RMN.
The evidence has been that Worthing Hospital’s missing person policy at the time was not formulated to give directions to hospital staff if a young person absconded. Despite having been rated as being at high risk of absconding, there was no clear plan on Bluefin Ward about what staff should do if Ellame (or another high-risk vulnerable mental health patient) absconded.
If Ellame absconded from the Ward, the hospital’s policy on absconding patients required staff to fast bleep security and follow the patient to the doors of the hospital, but no further. The inquest also heard evidence that neither RMN nor Bluefin Ward staff were permitted to chase after a patient who had absconded from the Ward.
Security officers and some nursing staff performed a search of the hospital grounds before informing Sussex police.
At 9.30pm, police found Ellame having ligatured in the hospital grounds. An ambulance was called and Ellame was taken into the hospital where she was declared dead shortly after.
Jury conclusions
The jury found that the medical cause of Ellame’s death was asphyxiation due to a ligature, though it was not possible to know if she had intended to take her own life. They also concluded that her condition of PTSD has more than minimally contributed to her death.
They also found the following failures to have more than minimally contributed to her death:
The Coroner indicated that she will be issuing a Prevention of Future Deaths (PFD) report to NHS England concerning the use of acute paediatric wards for children and young people requiring specialist psychiatric support.
In addition to this, the Coroner is considering a further PFD and has requested additional statements.
Ellame’s parents said:“Nothing can compare to the devastation that we feel at the loss of Ellame.
This will be further compounded if no lessons are learnt and no meaningful changes are made, as so often has been the case.
We therefore call on NHS England and Wes Streeting to increase funding for mental health services so that more young people aren’t left waiting for the care that they so desperately need, and other families don’t have to experience the worst thing imaginable, the death of their child.
We call on SPFT to create effective specialist provision for young people with mental health needs who are currently still inappropriately placed, like Ellame was, on local paediatric wards that are not set up to provide safe and positive mental health care."
Jodie Anderson, Senior Caseworker at INQUEST, said: “Ellame’s inquest has exposed a mental health system in Sussex that is crumbling at the seams.
A lack of specialist beds and a dismissive response to Ellame’s distress left her to languish in an unsuitable paediatric ward. A lack of urgency and professional curiosity was endemic throughout her care.
Too many families like Ellame’s have been failed by Sussex mental health services. Their collective fight for a system which responds with care and support to the distress of children and young people should inspire and compel us all to action. Lives are at stake.”
Ilaria Minucci of Birnberg Peirce said: “My clients are grateful to HM Coroner and the jury for their careful consideration of the crucial issues in this case. Sadly, Ellame’s story is an irreparable tragedy for her family, and they will bear the loss of Ellame for the rest of their lives.
Ellame’s case needs to remind us that stories like hers are not isolated instances, and that they reflect a crisis at the national level in respect of children’s mental health services that needs to be dealt with urgently.”
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Leila Hagmann on leilahagmann@inquest.org.uk.
The family are represented by INQUEST Lawyers Group members Ilaria Minucci of Birnberg Peirce and Oliver Lewis of Doughty Street. They are supported by INQUEST Senior Caseworker Jodie Anderson.
Other Interested persons represented are Sussex Partnership NHS Foundation Trust (SPFT), University Hospitals Sussex NHS Foundation Trust (UHSFT), a Registered Mental Health Nurse (RMN), West Sussex County Council, the Care Quality Commission (CQC), and the NHS Integrated Care Board (ICB).
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Deaths in the care of Sussex mental health services:
INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
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